The Impact of Preoperative Opioid Use on Patient Outcomes

A new study looked at the effects of front-end opioid prescribing for patients in need of knee, hip, or shoulder joint replacement, and it builds a growing evidence base that shows better patient outcomes and lower payer cost when opioids are tapered prior to surgery.

“Despite the many risks of opioid use, about 40% of patients in need of knee, hip, or shoulder joint replacement are commonly prescribed opioids prior to surgery,” says Elizabeth Ann Stringer, chief science and clinical officer, axialHealthcare. “This is problematic because studies have shown that preoperative opioid use is associated with higher health plan costs, worse outcomes, higher opioid use requirements during the surgical hospital stay, and a lower likelihood of discontinuing opioids after surgery when compared with no preoperative opioid use.”

The study, published in Pain Medicine Journal, of nearly 35,000 patients analyzed the effects of opioid use on outcomes during the surgical hospital stay and for up to 18 months following surgery for privately insured patients undergoing knee, hip, or shoulder replacement.

Conducted by researchers at Vanderbilt University Medical Center, Brigham and Women’s Hospital, and axialHealthcare, the study found that preoperative opioid users had:

• longer length of stay

• increased unplanned readmission

• higher surgical site infection

• increased revision rates

• higher spend

• persistent opioid use, which worsened with dose

Researchers also found that preoperative opioid users were more likely to have comorbid psychiatric disorders and incur high costs in the year before surgery. Specifically, a history of behavioral health disorders was higher in the preoperative opioid user group for mood or anxiety disorder, substance use disorder, and personality or trauma and stressor disorder, and medical spend was higher by about $2,000.

“The higher the opioid dose, the worse the observed effect on these outcomes,” says Stringer. “By leveraging data that spanned nationally across multiple healthcare institutions, the study produced generalizable results that are not limited by institutional standards of care like previous studies and build on the evidence for better patient outcomes and lower health plan costs when opioids are tapered prior to surgery.”

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Opioid prescribing related to surgical events has been identified as a contributor to the opioid epidemic and development of opioid use disorder in some patients, according to Stringer.

“Understanding subsets of patients with higher likelihood of continued opioid use postoperatively-in this case, those prescribed opioids prior to surgery-could contribute to more judicious opioid prescribing or awareness of the need for increased monitoring of these patients during and after their surgical hospital stay.”

Value-based hospital care

With the move toward value-based care and risk bearing payment models, providers, health plans, and hospitals need to understand patient risk factors and cost drivers for these types of procedures, according to Stringer.

“This study helps providers understand that opioid dose reduction prior to an elective joint replacement procedure could contribute to more positive surgical and patient outcomes, higher satisfaction rates, and lower costs,” she says. “Additionally, if preoperative opioid use contributes to outcomes that drive up costs, health plans may consider incentivizing providers for medically managed opioid dose reduction leading up to surgery or even requiring managed opioid tapering for high risk patients prior to approving.”

Hospital value-based purchasing measures commonly include knee, hip, and shoulder replacement procedures. “Hospitals reimbursed under these agreements may recognize preoperative opioid use as a modifiable risk factor for lowering postoperative readmission and surgical site infection rates, two outcomes that could negatively impact reimbursement for joint replacement procedures,” Stringer says.

The study results may also be valuable for patients undergoing elective joint replacement surgery, according to Stringer.

“Patients may not understand why a provider would ask them to gradually lower their opioid dose in the months prior to an elective surgery, but results of this analysis could help them understand that lowering their dose or safely discontinuing opioids prior to a procedure could increase their likelihood of a successful surgery and no longer requiring opioids for pain relief in the months following the procedure,” she says.