American Association of Hip and Knee Surgeons (AAHKS), American Society of Regional Anesthesia and Pain Medicine (ASRA), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, and Knee Society
Opioids in Total Joint Arthroplasty
This guideline holds 7 recommendations and 36 references.
Summary
This clinical practice guideline provides evidence-based recommendations regarding the use of opioids before, during, and after primary total joint arthroplasty (TJA). It highlights the risks of preoperative opioid use, advocates for prescribing the lowest effective quantity at discharge, and details the effects of perioperative opioids.
Developed collaboratively by major orthopaedic and anesthesia societies to address common questions related to the efficacy and safety of opioids in primary TJA, utilizing a systematic review and meta-analyses.
Key takeaways
Preoperative opioid use is linked to poorer patient outcomes and higher complication risks.
Reducing preoperative opioid consumption can yield better postoperative results.
Pre-emptive and intraoperative opioids lower early postoperative opioid needs but carry risks of respiratory depression if compounded with other doses.
Scheduled postoperative opioid administration is discouraged due to risks like sedation and respiratory depression.
Prescribing 30 versus 90 opioid pills at discharge offers equivalent pain control while minimizing unused medication.
Tramadol may help reduce postoperative pain and opioid usage, though it brings increased risks of dizziness and dry mouth.
Recommendations
Guideline Question 1
Preoperative opioid use is associated with inferior patient reported outcomes, increased opioid consumption after surgery, an increased risk for chronic opioid use, and an increased risk of complications after TJA.
Population: Patients undergoing primary TJAWhen: Preoperative opioid use
Guideline Question 2
Reduction of opioid use prior to TJA may lead to improved patient reported outcomes after TJA compared to patients who do not reduce opioid consumption prior to surgery.
Population: Patients undergoing primary TJA who consume opioids preoperativelyWhen: Reduction of opioid use prior to surgery
Guideline Question 3
An opioid administered immediately prior to surgery reduces postoperative pain and opioid consumption within the first 72 hours after TJA, but may increase the risk of complications, such as respiratory depression or sedation, especially if combined with other opioids administered intraoperatively or postoperatively.
Population: Patients undergoing primary TJAWhen: Opioids administered immediately prior to surgery
Guideline Question 4
An opioid administered intraoperatively reduces opioid consumption, but does not affect postoperative pain within 72 hours after surgery. An opioid administered intraoperatively may increase the risk of complications, such as respiratory depression or sedation, especially if combined with other opioids administered preoperatively or postoperatively.
Population: Patients undergoing primary TJAWhen: Opioids administered intraoperatively
Guideline Question 5
Scheduled opioid administration without multimodal analgesia within 72 hours after primary TJA reduces the need for additional opioid pain medications for breakthrough pain and may reduce postoperative pain within 72 hours after surgery, but providing scheduled opioids is discouraged. Scheduled opioid administration postoperatively may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other opioids administered during the perioperative period.
Population: Patients undergoing primary TJAWhen: Opioids administered after surgery
Guideline Question 6
Prescribing lower quantities of opioid pills at discharge may lead to equivalent patient reported outcomes, pain relief, reduced opioid consumption, and fewer unused opioid pills after TJA.
Population: Patients undergoing primary TJAWhen: Opioid pills prescribed at discharge
Guideline Question 7
Tramadol administered within 24 hours after surgery may reduce postoperative pain and opioid consumption after TJA within 72 hours after surgery, but may be associated with adverse events such as dizziness and dry mouth.
Population: Patients undergoing primary TJAWhen: Tramadol administered within 24 hours after surgery
