Elsevier

The Journal of Arthroplasty

Volume 38, Issue 2, February 2023, Pages 239-244
The Journal of Arthroplasty

Primary Hip and Knee Arthroplasty
Tapered Dose Postoperative Opioid Prescriptions Following Inpatient Total Hip and Knee Arthroplasty: Quality Improvement Study and Retrospective Review

https://doi.org/10.1016/j.arth.2022.08.043Get rights and content

Abstract

Background

Overprescription of pain medications directly fuels the opioid epidemic. Veterans are profoundly impacted. Tapered dose protocols may reduce excessive prescribing.

Methods

A retrospective study of adult veterans who presented to our institution for primary total knee arthroplasty or total hip arthroplasty (THA) was performed. Postdischarge opioid use was reviewed before and after an opioid taper prescription protocol. The preprotocol and postprotocol groups had 299 and 89 veterans, respectively. Total Morphine Milligram Equivalent (MME) prescribed postdischarge, number of tablets prescribed, number of refills issued, 30-day emergency department visits, and 30-day readmissions were compared. Opioid naïve and chronic opioid users were both included.

Results

Preprotocol and postprotocol implementation group, in combination with surgery type (total knee arthroplasty versus THA) and opioid naïve status, predicted MME. On average, the postprotocol group received 224 MME less, THA patients received 177 MME less, and nonopioid naïve patients received 152 MME more.

Conclusion

The opioid taper protocol led to less opioid administration after discharge. Taper protocols should be considered for postoperative pain management.

Level of Evidence

III, retrospective comparison study.

Section snippets

Materials and Methods

This project was determined to be a quality improvement project by our institution’s Institutional Review Board Committee. Charts were reviewed for patients aged 18 years and more who presented to our tertiary care university-affiliated VA hospital between January 1, 2018 and December 31, 2020 for total knee arthroplasty (TKA) and THA. Patients discharged to inpatient rehabilitation and patient floors for extended stays were excluded. Opioid naïve and nonopioid naïve (chronic opioid user)

Whole Group

The average Morphine Milligram Equivalent (MME) was 554 (standard deviation [SD] 384) in preprotocol implementation group but 292 (SD 335) in postprotocol implementations group. Baseline characteristics differed between the preimplementation and postimplementation groups. There was more cardiovascular disease, general gastrointestinal comorbidities, TKA surgery, and opioid naivety preimplementation but more substance use disorder, cancer, chronic kidney disease, and hyperlipidemia

Discussion

It is understood that postoperative opioid use increases the risk for chronic opioid use and addiction [24]. To address this phenomenon, tapering protocols for opioid use after surgery have been promising. In 2019, Tamboli et al at the Veterans Affairs Palo Alto Health Care System Orthopaedic Surgery Section designed a retrospective cohort study implementing a multidisciplinary patient-specific discharge protocol after THA. The Palo Alto protocol tailored the tapered opioid discharge

Conclusions

Our retrospective quality improvement study highlights the effectiveness of an opioid tapering protocol; we successfully reduced postoperative total opioid consumption. Furthermore, the protocol was well tolerated by patients. This successful project, coupled with the prior reported successful outcomes, suggests that research on postoperative opioid tapering protocols is warranted.

Acknowledgments

We would like to thank Dr Nicholas Giori, MD, and the Palo Alto VA for their assistance in sharing their opioid protocol. In addition, we would like to thank the Zablocki VA Pharmacy Department and Clinical Applications Coordinators for creating the patient instructions and order sets. Finally, we would like to thank Corey McKenzie, BS, and Maxwell Hershey, BS, for their efforts with data collection. This material is the result of work supported with resources and the use of facilities at the

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    • No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2022.08.043.

    This project was determined to be a quality improvement project by our institution’s Institutional Review Board Committee.

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