Opioid use, dependence and complications following musculoskeletal trauma and surgery

Long-term opioid use for chronic non-cancer pain has increased substantially. An increasing body of evidence is indicating that there has been an overestimation of benefit and an underestimation of harms, yet rates of use and dependence are not well quantified. The aims were to explore the incidence of prescription opioid use and dependence within an orthopaedic trauma and end-stage osteoarthritis population and to test a new model (a less-is-more-approach) for pain management after fracture surgery. Specifically, six studies were undertaken including five cohort studies and a single randomised trial. Main findings 1) Amongst an end-stage osteoarthritis population waitlisted for total hip or knee arthroplasty (THA; TKA) at NSW public hospitals, opioid use was common (25%) on entry to the waitlist and was associated with numerous individual characteristics; 2) Amongst a cohort including private THA and TKA patients, opioid use was common pre-operatively (17.8%) and post-operatively (41.5% 30-days, 18.1% 90-days), and pre-operative opioid use was a strong predictor of longer-term opioid post-operatively; 3): Within a non-admitted road trauma population, opioid use and dependence at 6 months was low; 3.3% and 0.8%, respectively. Opioid prescription at emergency department discharge was 33.3%; 4) Within a non-admitted fracture population, opioid use and dependence at 6 months was low; 4.2% and 1.2%, respectively. Opioid prescription at emergency department discharge was 47.4%; 5) In admitted major fracture patients, opioid use and dependence at six months after discharge was 17.6% and 8.9%, respectively. An opioid prescription upon discharge was 74%; 6) In a randomised trial, treatment with strong opioids was not superior to treatment with mild opioid after surgically managed orthopaedic fracture sub-acutely. Conclusions: Persistent opioid use after THA or TKA is common and predicted by pre-operative use, thus, more research testing mild- and non-opioid analgesics is required; Rates of opioid prescription following road trauma or fracture both in the non-hospitalised or hospitalised are high; Opioid use and dependence are low among the non-admitted populations; Admitted major trauma populations are being exposed to harms as indicated by ongoing long term use; while strong opioid use following discharge from hospital after surgically managed fractures has been found unnecessary