CONSENSUS RECOMMENDATION The systematic literature review yielded no studies that met inclusion criteria for this option. Outside the inclusion criteria, there is high quality evidence that oral opioids, including tramadol, result in a significant increase of adverse events and are not effective at improving pain or function for treatment of osteoarthritis of the knee. This led to a strong recommendation against the use of oral opioids for treatment of osteoarthritis of the knee in the AAOS Osteoarthritis of the Knee 3 Guideline. In addition to the risks associated with their use, preoperative opioid use is associated with increased risks of adverse events, complications, and revision in total hip arthroplasty. Patients who wean their opioid use before total hip arthroplasty have significant improvements in clinical outcomes after surgery compared to patients who continue their opioid use up until surgery.
Benefits/Harms of Implementation
Opioids have limited clinical benefit and are associated with significant adverse events. In addition, they increase the risk of complications after total hip arthroplasty.
Outcome Importance
The most important consideration will be removal of oral opioids from the medications prescribed in the treatment of osteoarthritis of the hip. This becomes particularly significant due to the rise of the opioid epidemic in the United States.
Cost Effectiveness/Resource Utilization
The optimal nonoperative treatment of osteoarthritis of the hip should reduce pain and improve function. It is the opinion of the workgroup that opioids do not lead to improvements in pain and function and increase the risk of adverse events. Thus, there are significant clinical risks and cost-associated risks with their use.
Acceptability
For most patients, this option should be readily implemented as it does not influence a major change in clinical practice. However, for patients who fail other nonoperative treatments, such as NSAIDs, acetaminophen or injections, there may be some resistance to this option. Importantly, these patients should be counseled on the significant risks associated with opioid use as well as their lack of efficacy.
Feasibility
This option should be easily implemented with no apparent barriers to adoption.
Future Research
Future research is needed investigating alternative non-opioid nonoperative treatments of osteoarthritis of the hip. For patients who present with chronic opioid use, future research is warranted to investigate ways to assist patients in weaning off opioids prior to total hip arthroplasty.