Tapering Opioids May Improve Arthroplasty Outcomes

Opioids commonly are used for pain management in patients with osteoarthritis. However, a new study has found that reducing opioid use by half prior to surgery may lead to better functional outcomes.

By Thomas G. Ciccone and Forest Tennant, MD, DrPH

Interview with Kevin J. Bozic, MD, MBA

Managing pain from knee or hip osteoarthritis (OA) is oftentimes a top priority—both for patients and physicians.¹ Although there is no cure for OA, opioids have become a common therapy for managing pain,^2,3 especially in patients who are unresponsive or can not tolerate anti-inflammatory medication.

Postoperative outcomes improve when patients cut their opioid use by half prior to surgery.Ultimately, however, many OA patients require total knee or hip replacement. The literature suggests that prolonged exposure to opioids could place patients at risk of complications following such procedures.

“There is pretty good evidence that patients who are on opioids before surgery either for arthritis pain or comorbid back conditions have worse outcomes following hip or knee replacement surgery,” Kevin J. Bozic, MD, MBA, from the Dell Medical School at the University of Texas in Austin,  told Practical Pain Management. “The purpose of our study was to see if this was a modifiable risk factor or not? If someone shows up in our office on opioids and we ask them to wean before surgery, is that likely to help them?”

What Was Found

The answer appears to be yes, according to the recentretrospective study by Dr. Bozic and colleagues.⁴ The study compared 3 cohorts of 41 patients each, all who underwent unilateral primary hip or knee arthroplasty procedure. One cohort of patients was opioid naïve, having no prior exposure to narcotics, while another cohort was considered opioid dependent, defined as chronic opioid use for at least 4 weeks. The third cohort of patients successfully cut their opioid dose by 50% by the time of surgery.

The results of the study found that the opioid naïve patients fared far better at 6 to 12 months after surgery compared with patients who continued to take opioids—showing much higher improvements in the University of California, Los Angeles Activity (UCLA), SF12v2 physical component, and The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores.

Interestingly, patients with a history of chronic opioid use who reduced their opioid dose (taper cohort) also showed significantly higher changes in UCLA, WOMAC, and SF12v2  scores compared with those who stayed on regular opioid regimens.

The results suggest patients who reduce preoperative opioid use may benefit from a similar rate of improvement in outcomes comparable to opioid naïve patients, noted the investigators. However, since the opioid naïve cohort’s baselines scores were much higher, patients that never took opioids still had significantly higher final UCLA, WOMAC, and SF12v2 physical component scores.

“Therefore, chronic opioid users who wean their dose of opioids before total joint arthroplasty can expect greater improvements in functional status and better overall functional status than chronic opioid users who do not wean, they should still be counseled to expect lower functional abilities than TJA patients who have not had chronic exposure to opioids,” the authors noted.

Chronic Opioid Use and Postsurgical Pain Outcomes: An Ironic Relationship

“There’s no doubt that for a short period of time immediately after a surgical procedure there could be some benefit to opioid pain medications,” Dr. Bozic said, who explained the study is not meant to shun practitioners away from utilizing opioids to manage pain in OA patients.

Some professional guidelines recommend the use of opioids for pain management of osteoarthritis, particularly after a patient inadequately responds to other treatments, such as nonsteroidal anti-inflammatory drugs or paracetamol, or is at risk for gastrointestinal bleeds or cardiovascular complications.^5,6

However, chronic opioid use prior to surgery has been linked to greater severity of acute pain and slower pain resolution despite necessary adjustments made for additional opioid administration.⁷ Also, opioid dependent patients often have prolonged hospital stays, more complications, additional surgical procedures, and greater need for postoperative pain management.^8,9

If opioid use prior to surgery is indeed a modifiable risk factor, it is unknown when a patient should begin to taper off their opioid dose. Opioid-maintained patients who significantly decrease or cease their opioids altogether just prior to surgery could suffer from a litany of dysfunctions in their autonomic nervous, endocrine, and immunologic systems, which can raise the risk of hypertension, poor recovery, withdrawal symptoms, infections, and other problems.

Unfortunately, the researchers did not have access to pharmacy records at the time, so they were not able to associate the duration and dose levels of preoperative and postoperative opioids with the patient reported outcomes. Larger doses of opioids have indeed been associated with opioid-induced hyperalgesia (OIH), which is thought to affect surgical outcomes in chronic opioid users.^10,11

According to Dr. Bozic, there is a “reasonable likelihood” that opioid dose and duration have an influence, although the explanation could include other important factors, as well. For instance, opioid use and weaning from opioids could be a surrogate for patient activation, where patients who are engaged in their healthcare and comply with postoperative care will portend more favorable outcomes, said Dr. Bozic.¹²

The hope is that doctors will consider first-line therapies like anti-inflammatories, when appropriate, before putting patients on an opioid regimen to manage OA symptoms, said Dr. Bozic. “The second point is: for those patients who are on opioids, we should discuss with them the fact that bringing down their dose before surgery has reasonably good evidence of helping lead to a better functional result after surgery, which is the goal of this surgery in the first place.”

For future research, Dr. Bozic intends to design a randomized, observational cohort study to try and establish causality. “The next step would be to prospectively assign patients to an intervention to reduce their depended narcotics preoperatively and so that would be the next phase of this work.”

1. Mordarski S. Pain management in the elderly: Transdermal fentanyl for the treatment of pain caused by osteoarthritis of the knee and hip.Biomed Res Int. 2014;2014:262961.
2. Goodwin JL, Kraemer JJ, Bajwa ZH. The use of opioids in the treatment of osteoarthritis: When, why, and how?Curr Rheumatol Rep. 2009;11(1):5.
3. Wright EA, Katz JN, Abrams S, et al. Trends in prescription of opioids from 2003-2009 in persons with knee osteoarthritis.Arthritis Care Res. 2014;66(10):1489.
4. Nguyen LL, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty.J Arthroplasty. 2016 Mar 17. [Epub ahead of print].
5. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.Arthritis Care Res. 2012;64(4):465.
6. Van Laar M, Pergolizzi Jr JV, Mellinghoff HU, et al. Pain treatment in arthritis related pain: Beyond NSAIDs.Open Rheumatol J. 2012;6:320.
7. Chapman CR, Davis J, Donaldson GW, et al. Postoperative pain trajectories in chronic pain patients undergoing surgery: The effects of chronic opioid pharmacotherapy on acute pain.J Pain. 2011;12(12):1240.
8. Zywiel MG, Stroh DA, Lee SY, et al. Chronic opioid use prior to total knee arthroplasty.J Bone Joint Surg Am. 2011;93(21):1988.
9. Pivec R, Issa K, Naziri Q, et al. Opioid use prior to total hip arthroplasty leads to worse clinical outcomes.Int Orthop. 2014;38(6):1159.
10. Lee M, Silverman SM, Hansen H, et al. A comprehensive review of opioid induced hyperalgesia.Pain Physician. 2011;14(2):145.
11. Tompkins DA, Campbell CM. Opioid-induced hyperalgesia: Clinically relevant or extraneous research phenomenon?Curr Pain Headache Rep. 2011;15(2):129.
12. Andrawis J, Akhavan S, Chan V, et al. Higher preoperative patient activation associated with better patient-reported outcomes after total joint arthroplasty.Clin Orthop Relat Res. 2015;473(8):2688.