Why is opioid use before hip or knee replacement a problem?

Patients who require THA or TKA suffer from end stage osteoarthritis with chronic pain. Opioids often provide no better pain relief that simple analgesics and yet they carry the risk of additional side effects such as drowsiness and the risk of falls. Moreover, opioid use before surgery is linked to worse outcomes including slower recovery and persistent opioid use three months after surgery.

THA and TKA are among the most common elective surgical procedures performed around the world and numbers are expected to at least double over the next decade.

The OpioidHALT trial (Feasibility of responsible pre-operative opioid use for Hip and knee ArthropLasTy (OpioidHALT) pilot study) was designed to examine the feasibility and acceptability of an intervention to reduce opioid use before elective THA or TKA compared to usual practice.

How OpioidHALT tackles pre-operative opioid use?

There is little published evidence for the effectiveness of opioid dose tapering. One previous retrospective study showed that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses.

The OpioidHALT study involved video or telephone consultations with a pharmacist starting three months before the date of the operation. The pharmacist worked with each patient to develop an opioid tapering plan that was evaluated for safety by a pain specialist. Patients determined the level of opioid tapering that they wished within the framework of national guidelines i.e. 10 to 25% of the patient’s baseline opioid dose tapered per month.

What the OpioidHALT pilot study tells us

The initial consultations in the OpioidHALT study took about one hour. Follow-up appointments started one week after each dose reduction and were typically shorter, Patients were educated about how to identify and manage opioid withdrawal symptoms. “If necessary, the patient was put back on a higher opioid dose”, says Dr Liu.

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses. The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts. In the intervention group there were –

• Fewer opioids consumed in hospital
• Smaller quantities of opioids supplied on discharge
• Fewer days in hospital
• Fewer patients taking opioids three months post-operation

Patients in the intervention group also had improved physical function and improved overall body pain intensity.

Why pharmacists should manage pre-operative opioid use

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago.

Recordings of the consultations showed that many patients were keen to discontinue opioid use but needed help with the process. “We’ve got patients who are crying [out] to have pharmacists to be more involved in their care …. and that’s something that a lot of pharmacists can do”, says Dr Penm. He adds that the whole multidisciplinary research team says “This is a really good intervention, we should be doing this, pharmacists should be leading it”

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

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Enhanced recovery after surgery (ERAS) is a really hot topic right now and there are protocols for almost any kind of surgery that you can imagine, according to Dr Tzabazis.  The overall goal for ERAS is to reduce perioperative complications and to achieve functional recovery as fast as possible – but not at the cost of additional complications. He describes this as a “better first, then fast” approach.

“We want to get the patients out of the hospital in better shape than they would be after a traditional approach but that does not necessarily mean we need to get them out of the hospital faster than usual so if they have to stay as long as they used to with the traditional approach that’s fine but the overall and very first objective is to get them out of the hospital better in better shape [than] they were with a traditional approach”, says Dr Tzabazis.

A multitude of approaches can be used to manage peri-operative pain. Regional anaesthesia has an important place. This could be by means of epidural administration, a nerve block or continuous peripheral nerve block. The other important approach is systemic administration of opioid and non-opioid analgesics, either at regular intervals or continuously using a syringe pump. Local anaesthetics might also be given, such as IV lidocaine (lignocaine).  There is now a big group of non-opioid analgesics – “that being ibuprofen, acetaminophen or paracetamol but then there’s also new additions such as the gabapentinoids. We also have ketamine- that’s a drug that is increasingly being used in perioperative pain management – and then we also have the alpha-agonists such as clonidine or dexmedetomidine. So we have really a huge armamentarium to treat perioperative pain from all kinds of different angles – and we should really use the best approach for individual patients”, says Dr Tzabazis

In practice, “you really need to tailor your approach to your individual patient and to the type of surgery that this patient is having”, he explains. For example, if a patient is undergoing major abdominal surgery with a big mid-line incision, the traditional approach [of] placing in a pre-operative epidural catheter is still valid. “However, we are now increasingly using a multimodal pain approach where we add IV or oral analgesic drugs as well and that is not only opioids but also increasingly non-opioids.  Some people have called this a ‘maxi-modal’ approach where we kind of try to … mix together all the different analgesics that we have available ….. to reduce side effects [compared with] one single medication.” In view of the opioid crisis, it is important to try to reduce opioid requirements in the immediate post-operative period and also in the long-term post-operative period, he comments.

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