Preoperative Opioid Use Increases Risk of Postoperative Narcotic Demand Following ACLR

Preoperative use of opioid medications in patients undergoing anterior cruciate ligament reconstruction (ACLR) is a strong predictor of postoperative opioid demand, according to study data presented at the 2017 annual meeting of the American Orthopaedic Society for Sports Medicine. According to the study's authors, the demand for narcotics drops significantly by the third month after surgery for most patients.

The authors note that postoperative opioid demand after ACLR is not well understood by surgeons and healthcare systems. The purpose of their study was twofold: First, to define the natural history of opioid demand after ACLR performed with and without concomitant procedures; and second, to evaluate preoperative opioid demand as a risk factor for postoperative demand.

"With the ever-increasing opioid epidemic our nation is facing, understanding the risk factors for postoperative narcotic use could aid surgeons and healthcare systems in identifying patients who could benefit from a different pain management and counseling regimen," explained the study's lead researcher Christopher A. Anthony, MD, of the University of Iowa Hospitals and Clinics.

"We hope that our research contributes additional information to the baseline opioid medication demand data and continues to increase our knowledge of how to avoid patient addiction following surgery," he added.

Study methods
Using Current Procedural Terminology code 29888 in a national health insurance database, the research team identified 4,946 patients who had undergone arthroscopic ACLR between 2007 and 2014. They categorized the patients into the following groups: ACLR alone, ACLR with meniscus repair, ACLR with meniscectomy, and ACLR with microfracture.

The researchers trended postoperative opioid demand by month for all patients for 1 year. To evaluate the effect of preoperative opioid demand on postoperative opioid use, they compared patients who filled preoperative opioid prescriptions to patients who had not. Patients were considered preoperative opioid users if they filled an opioid prescription in the 3 months preceding surgery.

Statistical analysis was used to calculate relative risk of postoperative opioid use; additionally, 95 percent confidence intervals (CI) were calculated.

Preoperative use associated with postoperative demand
The researchers found that opioid demand dropped significantly in most patients by 3 months following surgery. Among all patients, 7.24 percent (n = 358) filled prescriptions for opioids 2 to 3 months after surgery and 4.71 percent (n = 233) continued to fill opioid prescriptions at 1 year.

Analysis also revealed that, compared to patients in the other procedure groups, patients undergoing ACLR with microfracture were at increased risk of postoperative opioid use. Specifically, patients undergoing ACLR with microfracture were 1.96 (CI: 1.32-2.92) times as likely as patients undergoing ACLR alone, 2.38 (CI: 1.46-3.88) times as likely as patients undergoing ACL with meniscus repair, and 1.51 (CI: 1.03-2.23) times as likely as those undergoing ACL with meniscectomy to fill a prescription for narcotics 4 to 5 months after surgery.

Nearly 35 percent (n = 1,716) of the patients filled preoperative opioid prescriptions. These patients were 5.34 (CI: 4.12-6.94) times more likely, 7.54 (CI: 5.32-10.71) times more likely, and 6.42 (CI: 4.5-9.15) times more likely to fill opioid prescriptions at 2 to 3 months, 9 months, and 12 months, respectively, after ACLR than patients who did not fill preoperative narcotic prescriptions.

"We found preoperative opioid use to be a strong predictor of postoperative opioid demand, with a 5- to 7-fold increased risk in this patient population," the authors write. "Surgeons and healthcare systems should be aware [that] a large portion of patients undergoing ACLR are receiving preoperative opioid prescriptions, which puts these patients at increased risk for extended postoperative opioid demand. In the setting of preoperative care for patients who will undergo ACLR, healthcare providers should pursue nonopioid prescribing regimens in an effort to limit postoperative demand."           

Dr. Anthony's coauthors of "Opioid Demand after Anterior Cruciate Ligament Reconstruction" are Robert W. Westermann, MD; Nicholas Bedard; Natalie Glass, PhD; Matthew Bollier, MD; Carolyn M. Hettrich, MD, MPH; and Brian R. Wolf, MD, MS.

The authors' disclosure information can be accessed at www.aaos.org/disclosure.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org.

Bottom Line

  • Researchers evaluated pre and postoperative opioid use in 4,946 patients who had undergone arthroscopic ACLR with and without concomitant procedures.
  • Preoperative opioid users were 5 to 7 times more likely to demand opioid prescriptions following ACLR than patients who had not used the medications preoperatively.
  • Patients undergoing ACLR with microfracture were also at increased risk of postoperative opioid use compared to patients who had undergone ACLR alone or with meniscus repair or meniscectomy.
  • The authors recommend that to curb postoperative demand, healthcare providers should consider prescribing nonopioids preoperatively in ACLR patients.

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