The Utility of Routine Toxicology Screening and Substance Misuse Treatment Before Total Joint Arthroplasty in a Safety Net Hospital System.

Abstract

Preoperative substance use disorder (SUD) is an independent risk factor for complications and readmissions following primary total joint arthroplasty (TJA) of the hip and knee. In the context of value-based care, access to care for those who have SUD is threatened. In health safety-net (HSN) hospitals, the incidence of SUD has increased. This study aimed to determine the effect of universal toxicology screening to identify patients who had SUD for optimization before TJA. We hypothesized there would be a high yield of unexpected positive results and that delaying surgery for SUD treatment results in complication rates comparable to those who do not have SUD. Patients aged 18 to 90 years indicated for elective primary TJA at an urban, tertiary care HSN hospital underwent universal urine toxicology screening for opiates, benzodiazepines, cocaine, barbiturates, and amphetamines. Patients who had positive toxicology were required to undergo a minimum of 3 months of preoperative counseling and treatment by a SUD specialist. A multivariate analysis was performed to compare complications, readmissions, and reoperations for those who had positive versus negative tests. From October 2020 to December 2022, 723 patients underwent primary TJA, with 60% women and a mean age of 61 years. There were 19% who had a positive toxicology screen, of which 42% were unexpected positive results. Adjusting for age and American Society of Anesthesiologists class, patients who had a positive toxicology screen did not have an increased risk of aggregate medical and surgical complications (odds ratio) 0.67, 95% confidence interval [CI] 0.28 to 1.42, P = 0.33), readmission (odds ratio 0.14, 95% CI 0.01 to 0.65, P = 0.051), or reoperation (0.28, 95% CI 0.04 to 0.96, P = 0.086) in comparison to those who had negative tests. In an HSN setting, universal toxicology screening prior to TJA yields a clinically important rate of unexpected positive results. Preoperative SUD treatment with a minimum 3-month surgical delay was associated with outcomes comparable to those who had negative results and thus may improve care and outcomes for vulnerable patient populations.