Responsible opioid use before hip and knee replacement surgery

OpioidHALT: This will be a randomised controlled pilot study to establish the feasibility and acceptability of an intervention on the preoperative reduction of opioid use before elective THA or TKA compared to usual practice. Participants will be randomised in a 1:1 ratio to: (1) pharmacist tele-health consultation to individualise pain management and opioid tapering plans; or (2) usual care (Control). Intervention - Pharmacist-led opioid tapering: A pharmacist will contact the patient's General Practitioner (GP) by telephone to outline the intervention and address any concerns raised. With the GP’s approval for his/her patient to participate in the trial, the pharmacist will proceed to contact the participant. Participants will receive tele-health consultations with a Home Medicines Review accredited pharmacist. Pharmacist consultations will be based off the Behaviour Change Wheel for behaviour change interventions. The pharmacist will complete a pain management plan and an opioid weaning plan with the patient. We will use the pain management plan from NPS Medicinewise Australia, which will be tailored to the individual. A pharmacist trained in pain self-management will provide education on the development of pain self-management skills such as participating in physical exercise, learning relaxation techniques and implementing sleep hygiene practices. Necessary referrals to other health care professionals, such as physiotherapists, will be communicated to the patient’s GP to coordinate the patient’s care. The NPS opioid weaning plan will be used and involves an individualised tapering rate of 10-25% of the original opioid dose per week for patients on opioids for less than three months. Patients taking opioids for three or more months will taper opioids at a rate of 10-25% of the original opioid dose per month. The rate and end-point of opioid tapering will be guided by the pharmacist but will be patient-led, and individualised for dose, length of use and patient circumstances. The pharmacist will educate the patient on specific steps for the management of potential opioid withdrawal effects or increased pain. For example, if withdrawal effects are experienced, the patient will be instructed to pause tapering their opioid dose. If pain is experienced, the patient will be instructed to employ pain self-management strategies. If these effects persist, the patient will be instructed to increase their opioid dose. If withdrawal effects or pain persist beyond this, the patient will be instructed to see their GP. The completed pain management plan and opioid tapering plan will be reviewed by an Anaesthetist to ensure safety and effectiveness before they are sent to the patient’s GP to ensure continuity of care. Patients will receive follow-up appointments with the pharmacist one week after each opioid dose reduction to review tapering progress, address any difficulties encountered and adjust the opioid tapering plan as required. Opioid dose reduction will continue until a target of > 50% of the original daily opioid dose is tapered and the patient is clinically stable, without experiencing physical or psychological discomfort. The intervention will be administered a minimum of 3 and maximum of 12 months before surgery. Each telehealth consultation will be administered as at least 4 weekly sessions. Each session will approximately be 30 minutes in duration. Patients will receive a minimum of 3 sessions over approximately 3 months. Adherence to the intervention will be monitored using session attendance checklists and standard documentation forms. If the intervention ends before the patient is due for surgery, the patient will be asked to continue tapering their opioid dose with their GP using the given plans until the day of surgery. Patients who are ineligible for participation in the trial due to attendance at a pain clinic or those who are eligible but decline participation in the randomised trial will be invited to join an observation group. From the observation group, we will collect data by telephone at 3 months before surgery, 1 to 3 days before surgery, as well as information related to hospital stay upon hospital discharge from the electronic health record as outlined above. Patients will be offered a $50 gift card by email or by postage per telephone interview in return for their time. The value of the Observational arm is to provide a snapshot of opioid use of patients currently being managed by pain clinics. We will be able to see if opioid use among such patients increases or decreases whilst under the care of the clinic, thus providing indirect evidence of the need for an alternative intervention to help lower opioid use. In addition, there is a possibility we will recruit the people most keen to wean off their medications. By capturing data and following those who are eligible but are reluctant to participate in the randomize trial, we can compare whether those who refused have different characteristics to those who agree, and also obtain information about whether people are self-weaning or, conversely, actually increasing their opioid intake, and what happens to them.