CORR Insights®: Is the Preoperative Use of Antidepressants and Benzodiazepines Associated with Opioid and Other Analgesic Use After Hip and Knee Arthroplasty?

Few topics in orthopaedic surgery have received as much attention over the past 5 years as opioid prescriptions—and rightfully so. Less than 10 years ago, it was routine to send patients home with 150 opioid tablets after a primary total joint arthroplasty, if not more, often including long-acting opioids like oxycontin [⁷]. As the opioid epidemic worsened, it became clear that orthopaedic surgeons, as the third-leading prescribers of opioids [⁴], needed to take an active role in addressing the crisis. State and national governing bodies initially stepped in with guidelines for opioid prescription maximums in the form of a total number of days or oral morphine equivalents [¹]. Although well-intentioned, this blunt instrument for change failed to address procedure- and patient-specific needs. No one would argue that pain from a multilevel spine fusion should be treated similarly to pain following a carpal tunnel release.

Surgeons and hospital systems responded by creating guidelines of their own to provide a more nuanced balance between appropriate pain control and risk to patients and communities. Our team at the Mayo Clinic began by instituting new opioid prescription maximums that were 30% to 50% less than historic medians for the most common procedures in our department [¹³]. This achieved the initial aim, demonstrating a 50% decrease in median prescription size and marked decrease in prescription variability without a concomitant increase in refill rates [¹²]. Nevertheless, we still did not know whether these new targets were accurate based on how much opioid medication patients were taking. Subsequently, a team I was involved with performed a survey study that delineated how much opioid medication patients took after seven common orthopaedic procedures. Among the many takeaways from this study, we found that 60% of opioids went unused, but that the percentage varied greatly based on procedure and patient characteristics [¹⁴]. Our center’s guidelines were further refined, but still fail to consider patient-specific risk factors identified in the work such as diagnoses of anxiety or depression, age, and sex to name a few.

While previous work has suggested a relationship between anxiety and depression and higher opioid use after surgery, this connection has rarely been specifically investigated. Rajamäki and colleagues [⁸] provide important new insight on the topic in this issue of Clinical Orthopaedics and Related Research®. Analyzing approximately 20,000 patients who underwent primary THA and TKA between 2002 to 2011, the authors used multiple national registers in Finland to characterize analgesic use primarily based on diagnoses of anxiety, depression, or the use of medications to treat these conditions.

If there is one number to remember from this study, it’s two. After controlling for confounding variables, patients with anxiety or depression were roughly two times as likely as patients without those diagnoses to continue using opioids and nonopioid analgesics 1 year after surgery. This figure is troubling, especially as previous work has shown 3% to 6% of patients who were opioid naïve at the time of total joint arthroplasty continue using opioids at 6 to 12 months postoperatively, with rates of 14% to 53% among preoperative opioid users [^{2, 3}]. Based on these discoveries, surgeons should screen patients for anxiety, depression, and related mental health conditions, while working to also understand whether these conditions are well controlled. Just as we should screen patients for diabetes, counsel them on increased risk for infection, and delay surgery if their hemoglobin A1C levels are too high, we should counsel patients with depression or anxiety on possible challenges with pain control and consider delaying surgery if these conditions are not in good control prior to surgery preoperatively.