Opioid Use Following TJA Surgery

          Nine studies including six high quality studies and three moderate quality studies evaluated the influence of postoperative opioids on outcomes after primary TJA. A limited number of direct meta-analyses were performed due to inconsistency in outcomes reported and the timepoints at which these outcomes were reported. 

            Eight studies evaluated the postoperative consumption of opioids for breakthrough pain either delivered orally or with patient controlled analgesia between patients who received scheduled opioids postoperatively and patients who received placebo. All eight studies found that the administration of scheduled opioids postoperatively reduced the consumption of opioids for breakthrough pain.[24–31] Two studies were included in a direct meta-analysis with moderate heterogeneity and found that patients who were administered scheduled opioids postoperatively routinely required less opioids for breakthrough pain compared to placebo (-0.54 standard mean difference; 95% confidence interval of -0.92 to -0.15).

All nine studies evaluated postoperative pain and reported mixed results.[24–32]  Three studies reported no difference in pain control between patients who received scheduled opioids postoperatively and placebo.[25,26,31] Three studies reported mixed results where some pain measures were improved among patients who received opioids scheduled postoperatively while others pain parameters were no different between these patients and placebo.[28,29,32] The final three studies found that opioids administered after primary TJA reduce postoperative pain compared to placebo.[24,27,30] 

Direct meta-analyses evaluating complications associated with postoperative opioid use compared to placebo found no differences between the two groups in rates of respiratory depression (-0.17 standard mean difference; 95% confidence interval of -0.45 to 0.10), pruritus (1.01 relative risk; 95% confidence interval of 0.70 to 1.47), nausea (1.30 relative risk, 95% confidence interval of 1.03 to 1.65), vomiting (1.10 relative risk; 95% confidence interval of 0.69 to 1.74), confusion (1.82 relative risk; 95% confidence interval 0.35 to 9.49), dizziness (1.50 relative risk; 95% confidence interval 0.60 to 3.71), headache (0.69 relative risk; 95% confidence interval 0.30 to 1.59), and constipation (1.71 relative risk; 95% confidence interval 0.82 to 3.59). While the current literature does not demonstrate significant differences in rates of adverse events, it is the opinion of the workgroup that opioids pose significant risks to patients when not safely administered. The cumulative dose of opioids administered as well as the timing between opioid doses must be carefully monitored in TJA patients. Patients who receive excess opioid pain medication are at significant risk for adverse events such as sedation and respiratory depression. It is the recommendation of the workgroup that extended release opioids should be avoided to help mitigate this risk. In addition, it is the opinion of the workgroup that the lowest clinically effective dose of opioids be prescribed and administered to patients to help curb these adverse events in addition to the risk for chronic opioid dependence. Given the inconsistency in results with regards to postoperative pain as well as complications associated with postoperative opioid use this recommendation was downgraded from strong to moderate.