Evaluation of patient reported outcome measures between high-dose and low-dose opioid utilization following total knee arthroplasty,

Authors: Andrew R. Bohm, PhD, MS¹, Rebecca Teng, BA², Sarah Ulcoq, OTR/L², Giles R. Scuderi, MD¹

¹Lenox Hill Hospital, Northwell Health, New York, NY

²Force Therapeutics, New York, NY

Abstract

Introduction

In light of the opioid epidemic, it’s crucial to  evaluate the impact of postoperative pain  management options on patient reported outcomes  and recovery, and iterate on opioid prescribing   guidelines.  Patient reported use of opioids after Total Knee   Arthroplasty (TKA) is not well understood.  The American Society of Addiction Medicine (ASAM) recommends carefully assessing the benefits of an   opioid dose exceeding 50 morphine milligram   equivalents (MME)/day because of the additional  risks associated with exposing patients to higher opioid levels.  Utilizing patient reported dosage, we sought to test   if patient reported outcomes differ based on the ASAM threshold of high-dose opioid usage.

Materials & Methods

Patients undergoing primary TKA were enrolled on   an online-based physical therapy program per  standard of care.  Patients were asked to report daily pain and   medication usage at preoperative and 30 days after surgery.  Patients completed KOOs Jr, VR-12, and patient   satisfaction surveys throughout their care plan. Daily milligrams of morphine equivalent (MME)  were calculated from reported opioid type, dose,  and number of pills consumed to standardize across  opioids of different strength. Patients were categorized into 2 groups:  High-dose: use of excess of 50 MME/da, and Low-dose: use below 50 MME/day.  KOOS Jr, VR-12, patient satisfaction, and highest pain   evel were compared between the two groups at  preoperative and postoperative timepoints: 6 weeks, 12 weeks, 6 months, 1 year.

Results

150 patients (mean age 68, SD: 9.10) were enrolled   and included in this study.  33 patients (22%) took a dose in excess of 50   MME/day.  There were no statistically or clinically meaningful  differences in outcome measures between groups  across all postoperative timepoints (p values 0.08-0.92 across 16 different outcome timepoint   combinations).  12 week satisfaction scores did not differ between   the high-dose users (4.52) and low-dose users  (4.33), p=0.41.  Similar trend revealed in highest reported pain level  high-dose 7.88, low-dose 7.68, p= 0.63).

Discussion

No significant improvements in KOOS Jr, VR-12, or  patient satisfaction was shown at any timepoint  between high and low opioid dose groups.  Patients in both groups showed improvement in  KOOS Jr scores over time, but there were no  significant differences between the two groups at  any time point.  Similar trends were shown in VR-12 physical and   mental scores and the change in VR-12 physical  score was larger over time. Results suggest that no patient in the TKA   population should utilize a dose of in excess of 50   MME/day during recovery, as it doesn’t afford any   significant benefit in outcomes and only puts   patients at an increased risk of the ill effects of   high-dose opioid usage.  Monitoring patient medication is crucial for  assessing benefits and adjusting providers’   prescribing behaviors.