1. 2019;22;E395-E406Beta-blocker Use is Associated with a Reduction in Opioid Use 30 Days After Total Knee Arthroplasty
   Retrospective Review
   Irene Rozet, MD, Jordan Ben Starr, MD, and Miroslav Backonja, MD.

BACKGROUND: Total knee arthroplasty (TKA) can lead to chronic pain and prolonged postoperative opioid use. There are few evidence-based interventions to prevent these outcomes. Recently, beta-blockers have emerged as possible novel analgesics.

OBJECTIVES: The objective of this study was to determine whether perioperative beta-blocker use is associated with reduced prolonged postoperative opioid use after TKA.

STUDY DESIGN: This study used a retrospective cohort design.

SETTING: The research took place within Department of Veterans Affairs hospitals in the United States between April 2012 and April 2016.

METHODS: Patients: IRB approval was obtained to examine the records of Veterans Affairs (VA) patients undergoing TKA. Patients using opioids 60 days before surgery were excluded.

INTERVENTION: The intervention being investigated was perioperative beta-blocker use, overall and by class.

MEASUREMENT: Oral morphine equivalent usage through postoperative day 1 and prescription opioid refills through 30, 90, and 365 days after TKA were recorded. Adjusted models were created controlling for relevant demographic and comorbidity covariates. A secondary analysis examined the same outcomes separated by beta-blocker class.

RESULTS: The cohort was 93.8% male with a mean age of 66 years. Among the 11,614 TKAs that comprised the cohort, 2,604 (22.4%) were performed on patients using beta-blockers. After adjustment, beta-blocker use was associated with reduced opioid use through 30 days after surgery (odds ratio [OR] 0.89 [95% confidence interval (CI), 0.80-0.99], P = .026). Selective beta-blockers were associated with reduced opioid use at 30 days (OR 0.88 [95% CI, 0.78-0.98], P = .021), and nonselective beta-blockers were associated with reduced oral morphine equivalent usage through postoperative day 1 (beta = -17.9 [95% CI, -29.9 to -5.8], P = .004).

LIMITATIONS: Generalizability of these findings is uncertain, because this study was performed on a cohort of predominantly white, male VA patients. This study also measured opioid use, but opioid use is not a perfect surrogate for pain. Nevertheless, opioid use offers value as an objective measure of pain persistence in a national cohort for which patient-reported outcomes are otherwise unavailable.

CONCLUSIONS: Perioperative beta-blocker use was associated with reduced prescription opioid use at 30 days after surgery. Both selective and nonselective beta-blockers were associated with reduced opioid use when analyzed individually.

KEY WORDS: Analgesics, opioid, arthroplasty, replacement, knee, adrenergic beta-antagonists, pain management