PRE-OPERATIVE OPIOID USE

This recommendation has been upgraded due to increased risk of opioid overdose postoperatively. We reviewed various prospective and retrospective studies that represented the best available evidence. All articles provided low-quality evidence. These articles assess use of preoperative opioid use in patients and the outcomes after TKA. Two studies looked at tramadol use preop (Driesman 2019, Wilson 2021). When comparing patients who took tramadol preoperatively to patients who were opiate naïve, patients that used tramadol trended toward significantly less improvement in functional outcomes in terms of the Knee Disability Osteoarthritis Outcome Score (Driesman 2019). While tramadol-only use has lower risk than traditional opioids, tramadol-only use preceding TKA is associated with increased rates of readmission, wound complication, and revision surgery (Wilson 2021). Several studies looked at opioid use preop compared to patients that were opioid naïve. Patients on opioids preop had lower WOMAC, VAS scores and physical function scores at 1 year compared to opioid naïve patients (Goplen 2021). One study looked at revision total knee arthroplasty (Ingall 2021). Patients who are actively taking opioids at the time of revision TKA report significantly lower preoperative and postoperative outcome scores, PROMIS and KOOS scores. Kim (2019) found that after adjusting for baseline risk profiles, including comorbidities and frailty, continuous opioid users had a higher risk of revision operations and opioid overdose at 30 days post-TKA but not of in-hospital or 30-day mortality. A retrospective study done in approximately 30,000 patients showed that the use of preop opioids was a predictor of revision total knee arthroplasty (Starr 2018). There is consistent evidence to show poorer outcomes in patients that are on preop opioids compared to opioid naïve patients.

Benefits/ Harms of Implementation

There is significant benefit with limiting use of opioids preop. One study (Kim 2019) showed an increase in opioid overdose at 30 days post TKA.

Outcome Importance

The outcome of patients that are on preop opioids prior to TKA tend to be poorer than opioid naïve patients undergoing TKA.

Cost Effectiveness / Resource Utilization

Studies show increase in revision TKA, and longer hospital stays in patients on preop opioids which would not be cost effective.

Acceptability

The acceptability of this recommendation is high. There are several studies that show the benefits of limiting opioid use preoperatively.

Feasibility

The feasibility of this recommendation varies. It may be difficult for some surgeons to control opioid use in patients preoperatively if they are not the primary prescribers and if patients have pain sources other than their knee.

Future Research

Future research should include collaborative studies or efforts with pain management providers and/or primary care physicians. There is consistent evidence to show poorer outcomes in patients that are on preop opioids compared to opioid naïve patients. However, there is the need for more higher quality level one studies. Ethical considerations regarding level one studies must be considered as it would require patients to be blinded and randomized to narcotic use preoperatively and carries the risk of long-term addiction.