Effectiveness of Pre-Operative Opioid Tapering Methods for Orthopedic Surgery

SAKET GOHKALE, BS

Sidney Kimmel Medical College

SUMMARY POINTS

• Opioids are used preoperatively for a quarter of patients undergoing orthopedic surgery and are linked to postoperative opioid abuse.

• Personalized preoperative opioid plans and shared decision-making show a reduction in preoperative opioid usage. 

• Preoperative mental health screenings aid in predicting and reducing the probability of opioid abuse. 

• Further research on finding a balance between individualization and general criteria is needed to develop an efficient and effective protocol to taper opioids preoperatively. 

ANALYSIS

Background

Drug overdose has become a widespread epidemic in the United States, reaching a record level of 93,000 deaths in 2020. Recent studies show that 10 million Americans misuse opioids and 1.6 million have opioid use disorder (OUD). Opioid prescriptions after orthopedic surgeries to manage pain are a major source of misuse since patients are generally held responsible for self-tapering (1). Pre-operative opioid use and counseling have been shown to greatly influence post-operative pain levels as well as opioid abuse. 

About 25% of patients undergoing surgery have reported using opioids up to six months prior to date of operation (2). Methods involving limiting pre-operative use combined with increased counseling for those who need it the most have shown benefits after surgery. However, tapering plans tend to require personalization which hinders greater access. Also, this contributes to a more general form of preoperative opioid tapering which reaps fewer benefits. Thus, analyzing these methods and why they are effective can give a glimpse into more impactful solutions (3).

Another major facet to consider in addition to the preoperative opioid use itself are preexisting conditions that can put patients at risk after surgery. These include catastrophic thinking, anxiety, posttraumatic stress disorder, depression, other psychiatric diagnoses, family history of substance abuse, nicotine dependency, young age, and lower education level (4). These patients can be candidates for cognitive behavioral therapy to address potential addictive tendencies (5). As for the rest of the patient population, preoperative opioid informational videos and pamphlets on the inherent risks of opioid prescribing serve a crucial and efficient educational role in mitigating opioid misuse. 

FIGURE 1. Complications following total joint arthoplasty related to opioid use. See link for details. Marwaha JS, Beaulieu-Jones BR, Kennedy CJ, Bicket MC, Brat GA. Research priorities for the surgical care of patients taking opioids preoperatively. Reg Anesth Pain Med. 2022 Jun 17:rapm-2022-103584. doi: 10.1136/rapm-2022-103584. Epub ahead of print. PMID: 35715012.

Analysis

Preoperative opioid tapering is currently the most concrete method to reduce the probability of a post-operative opioid overdose. Uhbrand et al. investigated the effect of a personalized preoperative opioid tapering plan followed by telephone counseling one week after spine surgery. The study found a significantly lower percentage of patients who did not taper opioids prior to surgery as well as lower 3-month post-op opioid usage compared to the control group (6).  Shared decision-making was also embraced by patients, elucidating a positive response to the opioid tapering regimen. An additional benefit of pre-operative opioid tapering is a shorter postoperative hospital stay. Armaghani et al. found hospital stay to be extended by 1.1 days for every 100 morphine equivalent taken preoperatively. Additionally, preoperative prescription of opioids before THA and TKA had increased postoperative complications and opioid consumption (7). 

FIGURE 2. Postoperative opioid tapering effects on spine surgery outcomes. See Link: Uhrbrand P, Rasmussen MM, Haroutounian S, Nikolajsen L. Shared decision-making approach to taper postoperative opioids in spine surgery patients with preoperative opioid use: a randomized controlled trial. Pain. 2022 May 1;163(5):e634-e641. doi: 10.1097/j.pain.0000000000002456. PMID: 34433772.

Mental health also plays a crucial role in predicting post-operative opioid use disorder. While previously diagnosed mental health conditions such as anxiety and depression should trigger additional preventative measures, stressful periods before surgery can also reveal anxious and depressive symptoms that are undocumented. Therefore, tools such as Beck Anxiety Inventory (BAI) or the Zung Self-Rating Depression scale can be utilized to evaluate for anxiety and depression and should be routinely implemented. Only 45% of surgeons currently perform any mental health screening, even though they have been shown to mitigate opioid abuse by suggesting alternative pain management approaches (8).

Concurrently, substance abuse is also an indicator of mental health. These patients are prone to addiction and are thus at a higher risk for OUD. In addition, they may be more sensitive to pain, leading to an increased consumption of opioids post-operatively. Rodriguez-Merchan shows substance use leads to not only increased pain perception, but also greater occurrence of complications and need for revision following total joint arthroplasty (9). 

Discussion

Many more research studies are needed for the development of more concrete, efficacious preoperative opioid tapering methods (10). Shared decision-making is at the foundation of creating plans that reduce OUD post-surgery (10).  

Furthermore, a myriad of pre-operative techniques can be analyzed to see their individual as well as combined efficacy. These include multimodal pain management approaches, the use of non-opioid medications, regional anesthesia techniques, and enhanced patient education and monitoring (11). In addition, various peri-operative techniques can be investigated both individually and in conjunction with the aforementioned preoperative methods to achieve the most efficient and effective outcomes (11). 

Equal research efforts should be allotted to managing non-pain symptoms. Ideally, criteria can be developed which intersects a patient's pre-operative opioid use and mental health to arrive at an optimal peri and post-operative treatment plan. Application of this evidence-based criteria can place patients in groups dictating the best courses of action. 

The biggest challenge going forward entails finding a balance between standardization and personalization. The time-consuming nature of creating an individualized plan poses a challenge to providers in providing the best care possible. Thus, research in this area can lead to a more nuanced standardization for pre-operative opioid tapering.

REFERENCES:

1. Morris, Brent J. MD; Mir, Hassan R. MD, MBA, FACS. The Opioid Epidemic: Impact on Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons 23(5):p 267-271, May 2015. | DOI: 10.5435/JAAOS-D-14-00163

2. Marwaha JS, Beaulieu-Jones BR, Kennedy CJ, Bicket MC, Brat GA. Research priorities for the surgical care of patients taking opioids preoperatively. Reg Anesth Pain Med. 2022 Jun 17:rapm-2022-103584. doi: 10.1136/rapm-2022-103584. Epub ahead of print. PMID: 35715012.

3. Kylee Rucinski, James L. Cook. Effects of preoperative opioid education on postoperative opioid use and pain management in orthopaedics: A systematic review. Journal of Orthopaedics, Volume 20, 2020. Pages 154-159.

4. Kroenke K, Wu J, Bair MJ, et al. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain. 2011;12(9):964-973. doi:10.1016/j.jpain.2011.03.003

5. Wally MK, Hsu JR, Seymour RB. Musculoskeletal Pain Management and Patient Mental Health and Well-being. J Orthop Trauma. 2022;36(Suppl 5):S19-S24. doi:10.1097/BOT.0000000000002457

6. Uhrbrand P, Rasmussen MM, Haroutounian S, Nikolajsen L. Shared decision-making approach to taper postoperative opioids in spine surgery patients with preoperative opioid use: a randomized controlled trial. Pain. 2022 May 1;163(5):e634-e641. doi: 10.1097/j.pain.0000000000002456. PMID: 34433772.

7. Armaghani SJ, Lee DS, Bible JE, et al. Preoperative narcotic use and its relation to depression and anxiety in patients undergoing spine surgery. Spine. 2013;38(25):2196-2200. doi:10.1097/BRS.0000000000000011

8. Hassamal S, Haglund M, Wittnebel K, Danovitch I. A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series. Scand J Pain. 2016 Oct;13:27-31. doi: 10.1016/j.sjpain.2016.06.007. Epub 2016 Jul 4. PMID: 28850531.

9. E. Carlos Rodriguez-Merchan (2018) The importance of smoking in orthopedic surgery, Hospital Practice, 46:4, 175-182. 

10. Nguyen LC, Sing DC, Bozic KJ. Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty. J Arthroplasty. 2016 Sep;31(9 Suppl):282-7. doi: 10.1016/j.arth.2016.01.068. Epub 2016 Mar 17. PMID: 27105557.

11. Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg. 2017 Nov;125(5):1733-1740. doi: 10.1213/ANE.0000000000002458. PMID: 29049117; PMCID: PMC6119469.