Adequate relief of acute postsurgical pain is a metric of patient satisfaction
[1]
. Patients undergoing hip and knee arthroplasty — in which joints are altered or replaced — at Queen Elizabeth Hospital, Gateshead, receive strong opioids in the immediate postoperative period as part of a standard enhanced recovery bundle. The average length of stay for elective orthopaedic patients is 3.3 days, meaning patients often still require strong opioids at the point of discharge.
Studies have shown that an increased number of prescriptions for opioid medication has been accompanied by increased levels of prescription opioid overdose, abuse, addiction and diversion[2]
,[3]
. The longer the duration of opioid use, and the higher the dose taken, the greater the risk of long-term use, misuse and overdose[1]
,[2]
.
We investigated the impact of prescribing opioids for patients undergoing elective orthopaedic surgery on the longer term prescribing of opioids in general practice.
Data were collected retrospectively on 94 patients undergoing elective hip and knee arthroplasty at Queen Elizabeth Hospital during October 2017. Information on opioids taken before admission, opioids prescribed on discharge, and opioids prescribed by the patient’s GP three months after surgery (in January 2018) was collated for all patients. Some 15 patients were excluded because a complete set of information could not be obtained. Prescribing for the remaining 79 patients was compared for escalation or de-escalation at the point of discharge, and again at three months after discharge.
There was an escalation of opioid prescribing at the point of discharge towards strong opioids (41% of patients) and weak opioids (47%), from a pre-admission state of no opioids (52%) and weak opioids (42%).
At the three-month post-discharge assessment, the majority of patients were on no opioids (67%) with some prescribed weak opioids (28%); there was an overall de-escalation of opioid prescribing.
When comparing pre-admission and discharge prescribing, there was an escalation in prescribing for 47 patients (59%) and no change for 28 patients (35%).
Pre-admission data, compared with post-discharge data, show de-escalation in 17 patients (21%) and no change in 57 patients (72%).
Of the 17 patients who had their regimens de-escalated, 16 were reduced from weak opioids before admission to no opioid prescribing at three months after discharge.
Of the 57 patients who demonstrated no change to their opioid use between pre-admission and three months after discharge, 35 patients (60%) were not using any opioids before or after their surgery.
Some five patients (6%) showed an overall increase in opioid prescribing at the three-month point; these patients were started on a weak opioid (codeine or tramadol) following surgery, after previously being on no opioid.
The general practices of the five patients who had been escalated were contacted at 12 months. At this point, two of the patients (40%) had been discontinued from the opioid that had been started following surgery; one patient had recently had their dose reduced (20%); and the other two patients (2.5% of total patients included) were still receiving the opioid prescriptions from their GP.
This audit shows that prescribing of strong opioids within a protocol-driven ‘enhanced recovery’ arthroplasty at the Queen Elizabeth Hospital has a neutral or positive impact on the longer-term prescribing of opioids in 97.5% of patients; 65% of patients did not receive opioids three months after surgery, and 28% received the same level of opioid as prior to their surgery.
One benefit of joint arthroplasty is reduced pain, meaning lower analgesic requirements are to be expected; however, studies have reported continuation of opioid prescribing following surgery in opioid-naive patients[1]
. At 3 months, escalation of opioid prescribing was seen in 6% of patients; however, this fell to 2.5% when the patients were reviewed at 12 months, indicating a prolonged recovery time following surgery.
As up to 90% of joint arthroplasty is a result of osteoarthritis, a condition likely to affect multiple joints, it would be unrealistic to expect all patients to be completely pain free in the months following their surgery. Chronic pain from osteoarthritis could explain the continuation of opioids in some patients, and the escalation to weak opioids in other patients.
The prescribing of opioids in elective orthopaedic surgery at the Queen Elizabeth hospital is guided by standard protocols built into the electronic prescribing and medicines administration system, which results in patients receiving short courses of strong opioids only. The prescribing of strong opioids in other specialties — for example, general surgery and trauma — is currently less protocol driven, potentially leading to more variation in prescribing. The impact of prescribing opioids for discharge on the longer-term prescribing for these patients should be investigated in the future.
Lynsey Curry, lead clinical pharmacist for trauma and orthopaedics
Jonathan Fenwick, preregistration pharmacist
Neil Gammack, chief pharmacist
All at Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust
References
[1] Pino C & Covington M. Prescription of opioids for acute pain in opioid naïve patients. 2019. Available at: https://www.uptodate.com/contents/prescription-of-opioids-for-acute-pain-in-opioid-naive-patients (accessed March 2019)
[2] Chou R, Turner JA, Devine EB et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162(4):276–286. doi: 10.7326/M14-2559
[3] Brat GA, Agniel D, Beam A et al. Postsurgical prescriptions for opioid naïve patients and association with overdose and misuse: retrospective cohort study. BMJ 2018;360:j5790. doi: 10.1136/bmj.j5790
