Initial and Long-Term Prescribing of Opioids and Non-steroidal Anti-inflammatory Drugs Following Total Hip and Knee Arthroplasty

Abstract

Introduction Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA. Materials and Methods This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models. Results The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants. Discussion Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures. Conclusions Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing.