Prescription Patterns and Risk Factors for Prolonged Opioid Dependence in Elective Anterior Cruciate Ligament Reconstruction in a Military Population
Anderson AB, Balazs GC, Brooks DI, Potter BK, Forsberg JA, Dickens JF. Orthopaedic Journal of Sports Medicine. 2020 Jun; 8(6): 2325967120926489.
A female and/or someone with a history of substance abuse, preoperative opioid use, or more perioperative opioid use is more likely to be among the 28% of patients using opioids for ≥ 90 days after an anterior cruciate ligament reconstruction.
Opioid prescriptions have increased in recent decades, while nonsteroidal anti-inflammatory drug (NSAID) prescription has barely changed. Orthopedic surgeons are the third-highest opioid prescribers in the United States – behind primary care and internal medicine physicians. However, we know little about how type of surgery, demographics, and other risk factors affect acute and chronic opioid use among young, healthy, active individuals. Therefore, the authors sought “1) to identify rates of opioid use before and after anterior cruciate ligament reconstruction (ACLR), 2) to evaluate postoperative trends in opioid use for 1 year after ACLR, and 3) to identify and describe risk factors for prolonged opioid use after ACLR in an otherwise healthy, young, and active military population”. The authors accessed the US Military Health System Data Repository to identify 9,474 active-duty military patients (86% male) undergoing ACLR from January 2012 through December 2015, along with their diagnoses, opioid usage, and demographics. The authors focused on two main outcomes. First, they defined prolonged opioid use as use of opioids more than 90 days after surgery. Second, they looked at extreme postoperative opioid use, which was someone who filled prescriptions with dosages in the top 5% (based on morphine equivalents).
The authors found that oxycodone-acetaminophen (5-325 mg) was the most common opioid prescription, accounting for 34% of total prescriptions. About 1 in 5 patients filled an opioid prescription before surgery (30-120 days before surgery). Almost 3 out of 10 (28%) patients filled opioid prescriptions 90+ days after surgery. Finally, 8% of patients showed extreme opioid use. A person with a history of substance abuse diagnosis, older age (≥ 50 years), preoperative opioid use, and more perioperative opioid use was more likely to have extreme or prolonged opioid use. A woman was more likely to experience prolonged opioid use than a man. Furthermore, a white patient was more likely to experience extreme opioid use than a nonwhite.
The authors found that 28% of active-duty military patients used opioids more than 90 days after ACLR. Sex, age, preoperative and perioperative opioid use, and substance abuse diagnosis increased the odds of continued opioid use. Meanwhile, age, preoperative and perioperative opioid use, race, and substance abuse diagnosis increased the odds of extreme opioid use. It would be interesting if future studies could verify why the person was prescribed opioids after 90 days and if each patient used the medicine. Some patients may have filled prescriptions but not used the medication. Furthermore, the prescriptions may have been for pain unrelated to the surgery or prescribed because of chronic pain in someone with contra-indications for other therapies or who failed to respond to other therapies. It would also be interesting to learn if these patterns still exist today as awareness and training in substance abuse improve. For example, addiction medicine as a specialized service is new, with one-year fellowships now offered and the board exam being administered in 2017, 2-5 years after this study. Clinicians should consider these possible risk factors when discussing pain management before and after an ACLR to patients.
Questions for Discussion
Can improvements be made to our healthcare technology to alert physicians about high-risk patients or improper opioid prescriptions? How will the prescription and misuse of opioids change in the future?
Written by: Ryan Paul
Reviewed by: Jeffrey Driban
Oh boy, there’s a lot of opioids after an ankle sprain
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