Hospital and Surgeon Culture Drive Extended-Release Opioid Use After Arthroplasty

Institutional Drivers of Postoperative Opioid Prescribing

Total hip and knee arthroplasty are among the most successful interventions for end-stage osteoarthritis, yet managing acute postoperative pain remains a primary challenge for recovery and patient satisfaction [1]. Current clinical pathways emphasize multimodal analgesia, utilizing non-opioid adjuncts such as nonsteroidal anti-inflammatory drugs, gabapentinoids, and perioperative corticosteroids to minimize narcotic requirements [2, 3]. While regional anesthesia and specialized nerve blocks are recommended to facilitate early ambulation and reduce systemic adverse effects, the implementation of these techniques varies across clinical settings [4]. Despite clear guidelines discouraging the use of long-acting narcotics for acute surgical pain, prescribing patterns for potent analgesics often deviate from established evidence-based protocols. A comprehensive population-based analysis now examines the specific factors and institutional variations that influence the dispensing of extended-release opioids following major joint replacement surgery.

Incidence of Long-Acting Opioid Dispensing

The researchers conducted a population-based cross-sectional analysis of adults undergoing primary total hip or knee arthroplasty between 2013 and 2022. Utilizing linked administrative databases in Ontario, Canada, the study tracked the postoperative medication patterns of a massive cohort to identify how often clinical practice deviates from established safety guidelines. Although extended-release opioids (EROs), which are long-acting formulations designed for chronic pain management, are not recommended for the treatment of acute postoperative pain, the study confirms that their prescribing persists in surgical recovery settings. This misalignment with clinical recommendations is particularly concerning given the increased risks of respiratory depression and prolonged dependency associated with long-acting narcotics when used in opioid-naive patients for short-term surgical recovery. The primary outcome measured by the investigators was the fulfillment of an extended-release opioid prescription within seven days of hospital discharge. Among the 229,995 knee and hip arthroplasty procedures analyzed in this decade-long study, a significant subset of patients received these potent analgesics. Specifically, 27,915 patients, representing 12.1 percent of the total cohort, filled a new ERO prescription shortly after leaving the hospital. This finding highlights a substantial gap between evidence-based guidelines and real-world dispensing patterns, suggesting that more than one in ten joint replacement patients are exposed to long-acting opioids during the vulnerable early postoperative period.

Patient Risk Factors and Protective Anesthetic Interventions

To identify the specific drivers of extended-release opioid dispensing, the researchers utilized multilevel logistic regression (a statistical method that estimates associations between variables while accounting for how data are nested within groups, such as patients treated within the same hospital or by the same surgeon). This analysis identified several patient-level characteristics that significantly increased the likelihood of a patient receiving a long-acting opioid prescription. Male sex was associated with higher odds of filling a new extended-release opioid prescription (OR 1.14, 95% CI 1.09-1.19), as was a higher physical status according to the American Society of Anesthesiologists (ASA) classification. Specifically, patients with ASA 3 status, indicating severe systemic disease, had increased odds of filling these prescriptions (OR 1.07, 95% CI 1.01-1.12) compared to those with lower health risks. The study also quantified the impact of prior opioid use using the Opioid Naïve-Exposed-Tolerant (ONET) score (a metric that categorizes patients based on their recent history of opioid consumption). Patients with a preoperative ONET Score of 2, representing those previously exposed to opioids, showed increased odds of filling a new extended-release prescription (OR 1.21, 95% CI 1.15-1.27). This risk was even more pronounced in patients with a preoperative ONET Score of 3, representing opioid-tolerant individuals, who had the highest odds of receiving long-acting formulations (OR 1.38, 95% CI 1.20-1.58). Conversely, the researchers identified several modifiable anesthetic and perioperative interventions that served as protective factors. The use of neuraxial anesthesia, such as spinal or epidural blocks, was associated with a significant reduction in the odds of filling an extended-release opioid prescription (OR 0.79, 95% CI 0.74-0.84). Similarly, the administration of a peripheral nerve block was protective (OR 0.84, 95% CI 0.79-0.89), likely due to superior localized pain control in the immediate postoperative window. Furthermore, the involvement of an acute pain service, a specialized multidisciplinary team dedicated to managing complex postoperative analgesia, reduced the odds of extended-release opioid dispensing (OR 0.77, 95% CI 0.70-0.85). These results indicate that standardized anesthetic techniques and specialized pain management protocols can effectively mitigate the reliance on long-acting narcotics after joint replacement surgery.

Quantifying Variation Across Hospitals and Clinicians

To determine whether extended-release opioid prescribing was driven by clinical necessity or institutional habit, the researchers quantified variation using variance partition coefficients (VPCs) and median odds ratios (MOR). A variance partition coefficient (a statistical measure that determines the proportion of total variation in an outcome attributable to a specific level of the healthcare system, such as the hospital or the individual provider) was used alongside the median odds ratio (a metric representing the increased risk a patient faces when moving from a low-prescribing unit to a high-prescribing unit). The analysis revealed that hospital-level variation was the most significant driver of prescribing, with a VPC of 46% (95% CI 0.4-0.54) and a median odds ratio of 9.3 (95% CI 6.57-15.27). This suggests that nearly half of the variation in whether a patient receives a long-acting opioid is determined solely by the facility where the surgery is performed. The study also identified a substantial influence from the individual performing the procedure, while other members of the surgical team had negligible impact. Surgeon-level variation was quantified with a VPC of 26% (95% CI 0.24-0.26) and a median odds ratio of 5.3 (95% CI 4.63-6.11). In contrast, anesthetist-level variation was minimal, showing a VPC of only 1% (95% CI 0.010-0.011) and a median odds ratio of 1.4 (95% CI 1.36-1.46). These data indicate that while the choice of anesthesia affects individual patient outcomes, the broader decision to dispense extended-release opioids is rooted in surgical and institutional culture. Ultimately, patient-level factors explained only a minority of the variation in extended-release opioid dispensing, reinforcing the conclusion that one in ten patients fills an extended-release opioid prescription after total hip or knee arthroplasty due to institutional and surgical practice patterns rather than patient-specific clinical needs. For the practicing clinician, these findings suggest that reducing unnecessary opioid exposure requires a shift toward institutional stewardship and standardized discharge protocols rather than focusing solely on patient risk stratification.

References

1. Liu G, Gong M, Wang Y, Xiang Z. Effect of Methylprednisolone on Pain Management in Total Knee or Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.. The Clinical journal of pain. 2018. doi:10.1097/AJP.0000000000000614

2. Syed IM, Al-Rubaie S, Cohen D, Slawaska-Eng D, Al-Besher M, Khanna V. Non-Opioid Analgesics for Postoperative Pain Management Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.. The Journal of arthroplasty. 2025. doi:10.1016/j.arth.2025.03.027

3. Ibán MÁR, Oteo-Álvaro Á, Vázquez XM, Ávila JL, Ribera H, Pérez-Páramo M. Efficacy and safety of pregabalin for postoperative pain after total hip and knee arthroplasty: a systematic review and meta-analysis.. Journal of orthopaedic surgery and research. 2025. doi:10.1186/s13018-025-05675-6

4. Robin F, Newman N, Garneau S, Roy M. PROSPECT guidelines for total hip arthroplasty: a systematic review and procedure‐specific postoperative pain management recommendations. Anaesthesia. 2021. doi:10.1111/anae.15541