Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study

N Hussain; R Brull; I Gilron; T E Weaver; H Shahzad; R S D'Souza; M Abdel-Rasoul; H Clarke; C J L McCartney; F W Abdallah

doi:10.1111/anae.16259

Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study

Anaesthesia. 2024 Feb 22. doi: 10.1111/anae.16259. Online ahead of print.

Authors

N Hussain¹, R Brull², I Gilron³, T E Weaver¹, H Shahzad⁴, R S D'Souza⁵, M Abdel-Rasoul⁶, H Clarke^{7

8}, C J L McCartney⁹, F W Abdallah^{10

11}

Affiliations

¹ Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
² Department of Anesthesiology and Pain Management, Women's College Hospital and Toronto Western Hospital, University of Toronto, Toronto, ON, Canada.
³ Departments of Anesthesia and Perioperative Medicine and Biomedical and Molecular Science, Centre for Neuroscience Studies, School of Policy Studies, Queen's University, Kingston, ON, Canada.
⁴ Department of Orthopedics, UC Davis Health, Sacramento, CA, USA.
⁵ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
⁶ Department of Biomedical Informatics, College of Medicine, Center for Biostatistics, The Ohio State University, Columbus, OH, USA.
⁷ Department of Anesthesia and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.
⁸ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
⁹ Department of Anesthesiology and Pain Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Anesthesiology and Pain Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
¹¹ Department of Anesthesia, and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

PMID: 38385772
DOI: 10.1111/anae.16259

Abstract

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.

Keywords: non-steroidal anti-inflammatory drug; opioids; peri-operative pain management; persistent postoperative opioid use; total knee arthroplasty.