Associations between preoperative depression and opioid use after anterior cruciate ligament reconstruction and concomitant procedures
Best JM, Harris AB, Mohler JM, Wilckens JH. Phys Sportsmed. 2020 Nov 16. doi: 10.1080/00913847.2020.1851158. Online ahead of print
Patients undergoing an anterior cruciate ligament (ACL) reconstruction with preoperative depression were more likely to take opioids before surgery and obtain ≥1 opioid refill postoperatively. However, they did not have greater odds of chronic postoperative opioid use than those without preoperative depression.
Someone with depression is more likely to experience poor outcomes after an ACL surgery (decreased function, increased risk of substance abuse). However, we lack a clear understanding of whether depression relates to opioid use following ACL reconstruction.
The authors sought to determine rates of perioperative opioid use and characterize associations between preoperative depression and cumulative opioid consumption after ACL reconstruction.
Researchers used MarketScan Commercial Claims and Encounters Database to evaluate insurance claims data from 48,657 adults (18-65 years; 40% female) who underwent ACL reconstruction (CPT code 29,888) between 2010 to 2015. The authors included patients if they had prescription drug insurance and had > 1 year of continuous insurance enrollment postoperatively. A patient had depression if they had a qualifying diagnosis at any outpatient visit up to 6 months before surgery. Patients were classified as taking opioids preoperatively if they had filled at least one opioid prescription within 30 days before surgery. Opioid prescriptions filled from 7 days before to 7 days after surgery were classified as postoperative prescriptions. The authors measured mean duration of postoperative opioid use, rate of chronic opioid use (filling ≥120 days’ supply from 3 to 12 months after surgery), cumulative postoperative opioids prescribed (measured in milligrams, based on morphine equivalents), and differences in opioid usage according to the presence of preoperative depression.
Overall, 2,237 patients (4.6%) had depression, and 2,387 (4.9%) filled an opioid prescription before surgery. A patient with depression (59%) was 6.5 times more likely to fill an opioid prescription preoperatively than a patient without depression (10%). However, people with depression (6%) were ~80% less likely to fill an opioid prescription after surgery than someone without depression (26%). Among patients with an opioid prescription after surgery, those with depression were twice as likely to refill at least 1 opioid prescription than those without depression. Few patients used opioids for more than 120 days, regardless of depression.
The authors found that about 1 in 20 patients had depression before an ACL reconstruction. Among patients who underwent ACL reconstruction, those with preoperative depression were more likely to take and refill an opioid prescription; however, there was no association with chronic opioid use. This finding suggests that recognizing and treating depression may be necessary before surgery since 3 out of 5 patients with preoperative depression filled an opioid prescription. Similarly, more conversations about different pain management plans should be discussed as the primary goal preoperatively is to maintain range of motion and strength. Overall, the authors also found that people with depression were less likely to fill a prescription after surgery. However, this may be because the person was more likely to have opioids already from before surgery. It should be noted that the data collected during this time period was prior to the opioid regulations limiting prescriptions; therefore, it was a pleasant surprise that only 12% of the population were taking opioids preoperatively. It would be interesting to know if age, concomitant injuries, or pain scores relate to opioid use and if other medical professionals help with a patient’s pain management. For example, patients who are working with an athletic trainer may be relying on other modalities and therapeutic exercises for pain management preoperatively.
Medical professionals should understand the high prevalence of depression before surgeries and how depression influences outcomes. Ensuring a person with depression is recognized and treated before an ACL reconstruction may lead to less opioid use. Furthermore, medical professionals should continue to evaluate the use of ice, compression, and elevation before implementing opioids for pain management.
Questions for Discussion
Do you monitor athlete’s emotional symptoms such as depression and anxiety following injuries that result in the need of surgery? Are you involved with the pain management plan for your athletes? If so, what does that look like?
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Written by: Jane McDevitt
Reviewed by: Jeffrey Driban