Consensus Statement: Toward Opioid-Free Arthroplasty: A Leadership Forum

Seth Waldman, MD; Charles N. Cornell, MD; Louis A. Shapiro; Todd J. Albert, MD; William Schairer, MD; E. Carlos Rodriguez-Merchan, MD, PhD; Ellen M. Soffin, MD, PhD; Christopher Lee Wu, MD; Mark Barnes, JD, LLM; Alex Rich, MPH; Jonathan Avery, MD; Travis N. Rieder, PhD


March 28, 2019

Editorial Collaboration

Medscape &


As part of ongoing efforts to address the opioid crisis, on June 1, 2018, HSS Journal convened a multidisciplinary panel of experts for a daylong discussion: "Toward Opioid-Free Arthroplasty: A Leadership Forum."[1] Each invited participant presented on a specific aspect of the opioid crisis and/or pain management as it relates to total hip or knee arthroplasty. Representing orthopedics, anesthesiology, psychiatry, bioethics, health information technology, and law, this group crafted a consensus statement on appropriate pain management for total hip or knee arthroplasty. Many have also contributed to this special issue of HSS Journal on opioid prescribing and pain management (February 2019).

This consensus statement focuses on preoperative, perioperative, and postoperative strategies at the institutional and individual levels. It is not designed necessarily to guide clinicians in eliminating opioid prescribing, but rather to aid care teams in providing the best and safest postsurgical care possible.

The authors acknowledge that pain management amid the opioid epidemic is a shifting landscape and have arrived at this consensus as of December 2018. They offer it with the understanding that determining the best care for each patient requires ethical decision-making—weighing the risks and benefits of various pain-management strategies, including opioids.

Prescribers and Clinical Teams Must Identify At-Risk Patients

  • Preoperatively, determine a patient's need for a complex pain evaluation and opioid-management plan by obtaining a detailed history of chronic and acute pain, opioid use, and other substance use.

  • Confirm the clinician who has responsibility for each patient's pain-management plan, including determining medical need, ordering urine toxicity screening when appropriate, and checking state prescription drug monitoring databases.

Prescribers and Institutions Must Address Risk Stratification and Mitigation

  • Understand that the risks of opioid use after total joint replacement include not only dependency, addiction, and hyperalgesia (ie, worsened pain) but also an increased possibility of complications (eg, revision surgery).

  • Improve risk assessment by educating clinical staff on issues related to substance use disorder.

  • Implement risk-mitigation strategies, such as providing naloxone rescue kits for patients requiring high opioid doses and limiting initial dosage of discharge prescriptions.

Clinicians Must Establish Opioid-Responsible Prescribing and Education

  • Institute an opioid-responsible pain-management strategy for each patient. This involves identifying a single prescriber who uses evidence-based recommendations for prescribing opioids conservatively—that is, for the shortest duration and at the lowest dose to manage that individual's perioperative pain—and a plan for weaning while avoiding withdrawal symptoms.

  • Provide easy-to-understand fact sheets for patients that review the risks and benefits of opioid use, weaning, and safe storage and disposal (provide pill deactivation kits or locations for safe disposal, as well).

  • Commit to patient and family to reduce the risks of opioid use and manage withdrawal symptoms should they arise. Provide contact information of the prescriber whom patient, family members, or team members may call with questions.

  • Establish institutional standards to guide the use of opioids, ensuring quality improvement and monitoring in clinical practice and in the education and training of physicians, pharmacists, nurses, and other professional staff.

  • Refer patients when indicated for appropriate treatment of substance use disorder.


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