A Preoperative Opioid Tapering Guideline for Elective Joint Arthroplasty

J Parry*, K Donaghy*, K Wessels*, L Roberts*, B Hennessy*, M Majedi**, R Carey-Smith***
*Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Australia
**Department of Pain Management, Sir Charles Gairdner Hospital, Perth, Australia
***Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, Australia

 

Introduction: Joint arthroplasty significantly improves quality of life, improving function and reducing pain. In osteoarthritis, opioid risks outweigh benefits¹. Joint replacement outcomes improve with preoperative opioid dose reduction². Opioid-induced tolerance worsens postoperative analgesia. Moreover, opioids suppress immune function and infection risk may increase.

Aims: Service evaluation was performed to establish the number of patients attending anaesthesia pre-assessment clinic on high-dose opioids (morphine equivalent ≥ 80mg) prior to elective arthroplasty. Following a literature review and input from orthopaedic, pain management, anaesthesia and general practice (GP) specialists, an opioid tapering guideline was created.

Methods: During a two month period, anaesthetists in the preadmission clinic at a tertiary metropolitan teaching hospital collected audit data which were analysed with Microsoft Excel. A multi-disciplinary group developed the opioid tapering guideline.

Results: From September to November 2016, 37 of 984 preoperative patients (4%) were taking opioids (41% on high-dose opioids). Opioids were taken by 15 of 76 patients (20%) scheduled for arthroplasty. Thirty-one percent (5/15) of those patients were on high dose opioids. Tapering guideline criteria for patient referral back to their GP include high-dose opioids, opioid use with other infection risk factors (e.g. obesity, immunosuppressants), inappropriate opioid prescription (e.g. parenteral opioids) and prescription opioid addiction. The guideline recommends a tapering rate, opioid targets and provides pain clinic contacts for advice and support. Patients will be stabilised on an optimal opioid regimen for at least four weeks prior to elective arthroplasty.

Conclusions: Preoperative high dose opioids were less frequent than expected, indicating a manageable workload. The tapering guideline and GP referral will be administered from the orthopaedic outpatient department, aiming to taper opioids prior to a surgery booking date, reducing cancellation risk. Once fully implemented and audited, wider application of this guideline to other surgeries is planned.