According to a recent study from Brigham and Women’s Hospital (BWH), preoperative opioid use is associated with poor pain outcomes, leading study authors to propose  limiting opioid use prior to knee replacement surgery. 

A team of investigators from BWH have shown that preoperative opioid use leads to worse pain outcomes after total knee replacement (TKR) surgery. The research team compared pain relief in patients who used opioids before their TKR procedure versus those who did not.

The investigators, which includes lead author, Elena Losina, PhD, Director of the Policy and Innovation eValuation in Orthopedic Treatments Center (PIVOT Center), found that patients with higher pain catastrophizing were more likely to take opioids for pain relief. Patients who used opioids to manage their knee pain before their total knee replacement had less pain relief after the operation. The study was published on May 18, 2017 in the Journal of Bone and Joint Surgery.

The team reviewed data from 156 patients who had TKR (average age of 66-years-old). They collected patient-reported outcomes and demographic data before surgery and six months after surgery. They then abstracted data on opioid use from the patients’ medical records. Results show that prior to surgery, 23 percent of patients had at least one opioid prescription.

Using standard pain scales (Pain Catastrophizing Scale, the Western Ontario and the McMaster Universities Osteoarthritis Index (WOMAC)), the investigators quantified the pain experiences of patients who underwent TKR. Analytic methods were used to compare the change in the WOMAC pain score six months after knee surgery and to establish the difference between patients who did or did not use opioids prior to TKR. Patients who used opioids before surgery had approximately 9 percent less pain reduction at six months following surgery.

“Our findings support previous research that indicated preoperative opioid use was associated with worse clinical outcomes. This data demonstrates that preoperative opioid use may also lead to lesser pain relief in the early postoperative period,” says Dr. Losina.

The researchers note that since the U.S. spends over $1.5 billion annually on prescription opioids for patients with knee osteoarthritis, and nearly $30 billion on illicit use, reducing the use of opioids may decrease their harmful effects. Clinicians and policy makers may consider limiting the use of opioids prior to TKR to optimize post-TKR pain relief.

“Physicians should discuss the impact of opioid use with patients who have knee osteoarthritis and are considering TKR within the next two years,” says Dr. Losina, who also co-directs the Orthopedics and Arthritis Center for Outcomes Research at BWH.

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Opioids Use Quick Facts

1. Patients spend an average of 13 years using non-surgical options for pain management, including the use of NSAIDs, physical therapy, and intra-articular injections.

2. The U.S. spends more than $1.5 billion annually on prescription opioids for people with knee osteoarthritis.

3. About 40 percent of Medicare patients with knee osteoarthritis had at least one opioid prescription in 2009.