Prediction of Complications, Readmission, and Revision Surgery Based on Duration of Preoperative Opioid Use

TLDR

Preoperative opioid use leads to adverse outcomes and higher costs after elective surgery, yet the duration thresholds that increase risk remain unclear. The study aimed to determine how many and how long preoperative opioid prescriptions predict postoperative adverse events in major joint replacement and lumbar fusion using national insurance claims data. Cox proportional hazards models adjusted for demographics and clinical covariates assessed the effect of five preoperative opioid burden categories among 58,082 patients in TKA, THA, and PLF cohorts. Use of opioids for more than 3 months raised 90‑day ED visits and readmissions after TKA, while use for over 6 months increased ED visits, wound complications, readmissions, and revision surgery across all procedures; a 3‑month opioid‑free interval before surgery markedly reduced these risks, aligning chronic users with opioid‑naive patients. Therapeutic Level II evidence; see Instructions for Authors for full evidence level description.

Abstract

Preoperative opioid use results in adverse outcomes and higher costs after elective surgery. However, duration thresholds for higher risk are not entirely known. Therefore, the purpose of our study was to determine the number and duration of preoperative opioid prescriptions in order to estimate the risk of postoperative adverse events after major joint replacement and lumbar fusion.National insurance claims data (2007 to September 30, 2015) were used to identify primary total knee arthroplasties (TKAs), total hip arthroplasties (THAs), and 1 or 2-level posterior lumbar fusions (PLFs) performed for degenerative disease. The effect of preoperative opioid burden (naive, ≤3 months, >3 to 6 months, >6 months but stopped 3 months before surgery, and >6 months of continuous use) on the risks of various adverse outcomes was studied using Cox proportional hazards analysis with adjustment for demographic and clinical covariates.A total of 58,082 patients stratified into 3 cohorts of 32,667 with TKA, 14,734 with THA, and 10,681 with 1 or 2-level PLF were included for this analysis. A duration of preoperative opioids of >3 months was associated with a higher risk of 90-day emergency department (ED) visits for all causes and readmission after TKA. Preoperative opioid prescription for >6 months was associated with a higher risk of all-cause and pain-related ED visits, wound dehiscence/infection, and hospital readmission within 90 days as well as revision surgery within 1 year after TKA, THA, and PLF. Stopping the opioid prescription 3 months preoperatively for chronic users resulted in a significant reduction in the risk of adverse outcomes, with the greatest impact seen after THA and PLF.Patients with a preoperative opioid prescription for up to 3 months before a major arthroplasty or a 1 or 2-level lumbar fusion had a similar risk of adverse outcomes as opioid-naive patients. While >6 months of opioid use was associated with a higher risk of adverse outcomes, a 3-month prescription-free period before the surgery appeared to mitigate this risk for chronic users.Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.