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Acute Pain Is Associated With Chronic Opioid Use After Total Knee Arthroplasty
  1. Hung-Lun Hsia, MD*,,
  2. Steven Takemoto, PhD,,
  3. Thomas van de Ven, MD, PhD*,,
  4. Srinivas Pyati, MBBS, MD, FCARCSI*,,
  5. Thomas Buchheit, MD*,,
  6. Neil Ray, MD, MMCi,
  7. Samuel Wellman, MD§,
  8. Alfred Kuo, MD, PhD,
  9. Arthur Wallace, MD, PhD and
  10. Karthik Raghunathan, MD, MPH*,
  1. *From the Department of Anesthesiology, Duke University Medical Center and Anesthesiology Service, and
  2. The Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, NC;
  3. Anesthesiology Service, San Francisco VA Medical Center, San Francisco, CA;
  4. §Department of Orthopedics, Duke University Medical Center, Durham, NC; and
  5. Orthopedic Service, San Francisco VA Medical Center, San Francisco, CA
  1. Address correspondence to: Karthik Raghunathan, MD, MPH, Department of Anesthesiology, Division of Veterans Affairs, Duke University Medical Center, DUMC 3094, Durham, NC 27710 (e-mail: Karthik.raghunathan{at}


Background and Objectives Pain scores are routinely reported in clinical practice, and we wanted to examine whether this routinely measured, patient-reported variable provides prognostic information, especially with regard to chronic opioid use, after taking preoperative and perioperative variables into account in a preoperative opioid user population.

Methods In 32,874 preoperative opioid users undergoing primary total knee arthroplasty at Veterans Affairs hospitals between 2010 and 2015, we compared preoperative and perioperative characteristics in patients reporting lower versus higher acute pain (scores ≤4/10 vs >4/10 averaged over days 1–3). We calculated the propensity for lower acute pain based on all available data. After 1:1 propensity score matching, to identify similar patients differing only in acute pain, we contrasted rates of chronic significant opioid use (mean >30 mg/d in morphine equivalents) beyond postoperative month 3, discharge prescriptions, and changes in postoperative versus preoperative dose categories. Sensitivity analysis examined associations with dose escalation.

Results Rates of chronic significant opioid use (21% overall) differed in patients with lower versus higher acute pain (36% vs 64% of the overall cohort). After propensity matching (total n = 20,926 patients) and adjusting for all significant factors, lower acute pain was associated with less chronic significant opioid use (rates 12% vs 16%), smaller discharge prescriptions (ie, supply <30 days and daily oral morphine equivalent <30 mg/d), and more reduction in dose, all P < 0.001. In sensitivity analysis, dose escalation was 15% less likely with lower acute pain (odds ratio, 0.85; 95% confidence interval, 0.80–0.91).

Conclusions Acute pain predicts chronic opioid use. Prospective studies of efforts to reduce acute pain, in terms of long-term effects, are needed.

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  • This work was funded by the VA National Center for Patient Safety, Field Office 10A4E, through the Patient Safety Center of Inquiry at the Durham VA Medical Center.

  • The authors declare no conflict of interest.

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