Following a total knee replacement (TKR), opioids should be prescribed in the lowest dose and for the shortest duration possible.1 The Bree Collaborative and Washington State Agency Medical Directors’ Group 2015 guidance states that for Type III post-operative pain management, prescription opioids should be initially prescribed in the lowest dose possible for a maximum of 14 days after surgery.2 Type III procedures include those expected to have a longer recovery time, such as TKR. Patients experiencing high levels of sustained pain after two weeks should be re-evaluated for additional medication, but fully tapered from their surgery-related opioid prescriptions within six weeks of their surgery.2 To properly taper opioid prescriptions, the Guidelines on the Management of Post-Operative Pain published by the American Pain Society suggest a 20% – 25% reduction in opioid discharge dose each day or two days once pain begins improving to reduce the probability of withdrawal symptoms.3
One study comparing 641,941 opioid-naïve surgical patients to 169,666 opioid-naïve non-surgical patients showed that surgical patients were at an increased risk for long-term opioid use after surgery, and the highest incidence of chronic opioid use occurred after TKR (odds ratio 5.10, 95% confidence interval [4.67 – 5.58], p<.001).4 To combat this increased risk, physicians may educate their patients on the proper use of opioids, develop a pain management plan with their patients and the patient’s family members, and encourage the use of non-opioid pain management medications and methods such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDS), exercise, and heat or cold therapy.2,3 Patients taking preoperative opioids for other conditions were also more likely to exhibit sustained increase in prescription opioid use after TKR and should work with a physician to properly taper to a maintenance dose.3,5,6
References
- Dowell D, Haegerich TM, Chou R. CDCguideline forprescribing opioids for chronic pain--United States, 2016. JAMA. 2016;315(15):1624-1645.
- Washington State Agency Medical Directors’ Group. Interagency guideline on prescribing opioids for pain. State of Washington, Department of Health Washington; 2015.
- Chou R, Gordon DB, de Leon-Casasola OA, et al. Management ofpostoperativepain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-157.
- Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of andriskfactors for chronic opioid use among opioid-naïve patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293.
- Berna C, Kulich RJ, Rathmell JP. Taperinglong-termopioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc. 2015;90(6):828-842.
- Fujii MH, Hodges AC, Russell RL, et al. Post-discharge opioid prescribing and use after common surgical procedure.J Am Coll Surg.2018;226(6):1004-1012.
