Background and Aims Despite important indications benzodiazepine-associated risks may be exacerbated in elderly patients. Given the lack of national data, we aimed to describe perioperative benzodiazepine utilization patterns in total hip/knee arthroplasty (THA/TKA) recipients, an increasingly older and vulnerable population.

Methods Utilizing Premier Healthcare national claims data, we included TKA and THA cases from 2006 to 2019. Benzodiazepine utilization (long- and short-acting agents) was assessed by patient- and healthcare characteristics. Standardized differences signified meaningful differences between groups (defined by value >0.1).

Results Among 1,863,996 TKA and 985,471 THA patients, the utilization of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short- while 7.9% received long-acting benzodiazepines; respectively 68.4% and 7.7% in THA.

Benzodiazepine use was more frequent among younger and white patients, those on commercial insurance, patients receiving neuraxial or regional anesthesia, multimodal analgesia, in small and medium sized (<=500 beds) hospitals, and in the Midwest; all standardized differences ≥0.1. Similar patterns were observed in THA.

Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (in oral morphine equivalents OME) was substantially higher. This was even more pronounced among those receiving long-acting benzodiazepines (median OME with no benzodiazepines utilization 192[IQR 83–345] versus 256[IQR 153–431] with short-, and 329[IQR 195–540] with long-acting benzodiazepines).

Benzodiazepine utilization was persistent high over the past 14 years.

Conclusions In the US, 4 out of 5 patients undergoing major orthopedic surgery receive benzodiazepines perioperatively, despite concerns for neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, potentially indicating implications for perioperative pain management.