Momentum Builds for Opioid-Free Total Joints

Mo Halawi, MD, grew up in Lebanon, where he remembers his grandmother receiving acetaminophen to manage her pain after a major surgery. When he began practicing medicine in America, he was surprised to see surgeons passing out opioids like candy. “In many other countries, over-the-counter medications are sufficient to treat post-op pain,” says Dr. Halawi, an orthopedic surgeon and joint replacement specialist in Houston. “The perception of pain is different in the U.S., where there’s a reflexive culture to use opioids as an immediate intervention. But opioids cause a host of unwanted side effects after surgery. Instead of complaining about pain, patients suffer from non-surgical issues such as constipation, nausea and vomiting.”

In 2017, Dr. Halawi began to reduce the amount of opioids he gave to total knee replacement patients. He continually assessed patient feedback throughout the process and received very few calls from patients complaining of excessive post-op pain. A year later, he wrote his last script and has never regretted the decision to go opioid-free. Dr. Halawi, like an increasing number of providers, discovered multimodal care pathways help patients survive the acute pain of surgery — and thrive during their recoveries.

The gradual movement toward eliminating opioids from the care plan of total joint patients is similar to the steady migration of the procedures from inpatient hospitals to outpatient ORs, according to Vinod Dasa, MD, a professor of clinical orthopedics and clinical research at LSU Health New Orleans School of Medicine. His journey to same-day joint replacements began in 2013. Since then, he’s been tweaking and improving the protocols he uses to improve outcomes, including the techniques he employs to ensure patients recover in comfort.

In 2019, Dr. Dasa began to reduce the number of opioids he prescribed to his patients and saw they recovered extremely well from surgery. He knew that going opioid-free was possible, but he needed an opportunity to incorporate the concept into everyday practice. It came during the pause of elective surgeries at the height of the pandemic, which allowed him to hit the reset button on his pain management protocols. “I informed my team that we were going to stop prescribing opioids when procedures resumed,” says Dr. Dasa. “And we did it. The sky didn’t fall. The world kept spinning.”

Dr. Dasa decided to track outcomes for the first 40 total knee patients he operated on after the restart of surgeries and reported on the results for a case series study he recently published. Of the 32 patients who were opioid-naïve, 26 (about 85%) needed only acetaminophen and NSAIDs after surgery for effective pain control. The patients who did request medications to treat breakthrough pain were given tramadol, a less potent opioid than oxycodone. When those outcomes are factored into the study’s results, Dr. Dasa says about 95% of the patients did not require a powerful narcotic to keep their pain under control. The results validated his push for opioid-free knee replacements — arguably one of the most painful procedures patients undergo.

No one can argue that the indiscriminate use of opioids to manage post-op pain jeopardizes safe patient care, but changing the prescribing patterns of surgeons remains a challenge. Dr. Dasa says most physicians understand the importance of limiting opioid use at a high level, but don’t do it on a daily basis. “There’s no incentive other than perhaps goodwill and an understanding that the national epidemic is a major issue,” he says. “Surgeons often think someone else will address the problem and continue to prescribe opioids.”

Dr. Dasa and his colleagues are currently working with basic scientists, anatomists, physiologists and neuroscientists to create an opioid mitigation initiative curriculum specifically designed for surgeons with the goal of creating a patient-centric approach to perioperative care. The program, which involves didactic teaching and cadaver workshops to improve surgeons’ understanding of neuroanatomy and pain pathways, covers all aspects of opioid-reducing strategies throughout the entire episode of care. The program is targeting surgical residents — a captive audience and a new generation of providers who will hopefully enter practice with a fresh approach to post-op pain management — but surgeons of all levels of experience are invited and encouraged to participate. 

Dr. Dasa says the educational sessions are effective and inspiring. “Specialists from numerous disciplines participate in fascinating and informative conversations about different aspects of patient care,” he explains. “You can see the wheels turning, and light bulbs going off. We’re all learning from each other.”

The movement to treat pain as the “fifth vital sign” was born two decades ago of good intentions but resulted in unintended consequences, including the overprescribing of opioids that has increased the risk of misuse and potential abuse — a significant factor to consider as the opioid epidemic continues to ravage communities across the country. Research has also shown that the effects of opioids last longer than the duration for which they’re taken and have beyond-recovery implications, according to Dr. Halawi.

An effective pain management strategy involves a constellation of elements.

To help curb the overuse of opioids, his patients have a strong grasp of what their recovery will be like before they undergo surgery, and this clear expectation gives them the mentality they need to take ownership in their care and the ability to endure the pain they experience. He tells patients that the effectiveness of the individual components of his multimodal pain management regimen is based on the synergistic sum of their parts. The results speak for themselves. At the two-week follow-up appointments in his clinic, most of his patients are already beginning to transition back to their normal life routines.

His opioid-free regimen improves outcomes and the patient experience, and ultimately their satisfaction with the level of care they receive. “Many providers believe opioid use improves the management of postoperative pain and therefore increases patient satisfaction,” says Dr. Halawi. “I’ve found the opposite is true. Patient satisfaction is built on delivering successful and reproducible outcomes without resorting to the use of opioids, which solve one problem but create others, including unnecessary complications and the risk of dependence.”

Patients must understand that opioids aren’t needed to manage their pain — and buy into the concept. Changing their expectations is an often-discussed part of eliminating the use of opioids from joint replacement care — to the point of sounding cliché — because it’s an essential component of an initiative’s success, according to Dr. Halawi. “Most patients have a great deal of skepticism when they’re told their pain will be effectively managed without opioids,” he says. “But after surgery, they’re often shocked by how well they feel.”

A woman who recently underwent a knee replacement performed by Dr. Halawi posted a review on his website that said she wouldn’t even have realized she had surgery if it wasn’t for the scar. It’s real-world feedback like that that shows opioids aren’t needed to dull the pain of intensely invasive procedures after which patients want to recover in comfort at home. As the demand for outpatient total joint procedures continues to climb, this realization is more important than ever for patients and the providers who care for them. OSM