Receipt of Extended-Release Opioids After Total Hip or Knee Arthroplasty and Subsequent Persistent Postoperative Opioid Use and Health System Utilization: A Population-Based Comparative Effectiveness Analysis

BACKGROUND: Extended-release opioids (EROs), continue to be used for acute pain following surgery despite guideline recommendations discouraging their use. We examined the association of filling a new postoperative ERO prescription with persistent postoperative opioid use (PPOU), clinical events, and health system outcomes among patients undergoing total hip or knee arthroplasty. METHODS: We conducted a population-based comparative effectiveness study of adult residents of Ontario, Canada, undergoing elective primary total hip or knee arthroplasty between 2013 and 2022. Using linked administrative datasets, we identified patients who filled an ERO prescription within seven days of discharge. The primary outcome was PPOU, defined using a measure accounting for preoperative opioid exposure (O-NET). Secondary outcomes included 90-day readmissions, 90-day emergency department (ED) visits, 365-day days alive at home (DAH), and 365-day total health system costs. Associations were estimated using propensity score overlap weighting to balance demographic, clinical, and perioperative covariates. RESULTS: Among 258,624 patients, 31,224 (12.1%) filled a new postoperative ERO prescription. Among those who filled an ERO prescription, 1,860 (6.0%) developed PPOU, compared to 11,804 (5.2%) without ERO. After weighting, filling an ERO prescription was associated with increased odds of PPOU (adjusted odds ratio [aOR] 1.08, 95%CI 1.01-1.15), higher 90-day readmissions (aOR 1.09, 95%CI 1.02-1.17) and ED visits (aOR 1.16, 95%CI 1.12-1.21). In contrast, total health system costs were lower (ratio of means [RoM] 0.87, 95%CI 0.85-0.89) and DAH were higher (RoM 1.002, 95%CI 1.0004-1.003) at 365 days. CONCLUSIONS: Using O-NET criteria, 6% of patients receiving new postoperative ERO prescriptions develop PPOU. Filling a new ERO prescription was associated with small but consistent increases in adverse clinical outcomes balanced against decreased 1 year health system costs. Combined with concerns regarding opioid-related harm and the opioid epidemic, these findings reinforce a cautious approach in postoperative ERO prescribing.