Prescribing of opioids for patients awaiting hip and knee replacement surgery increased significantly during the COVID-19 pandemic, according to a study published in BMJ Quality and Safety.
The study, carried out by researchers at the University of Aberdeen, Scotland, looked at data collected from 548 NHS patients from the north east of Scotland.
They compared patients on the outpatient waiting list for primary hip and knee arthroplasty, as of September 2020, with historical patients who had had surgery before the pandemic, and found that the proportion of patients prescribed weak opioids (codeine/dihydrocodeine/tramadol) was around 40% (132/260 vs 99/272) higher in the waiting list group.
The median waiting time from referral to follow-up was an average of 90 days (455 days vs 365 days; P<0.0001) longer during the pandemic, compared with the waiting time experienced by the historical patients.
Researchers said that patients awaiting hip and knee replacements — one of the most common elective procedures — were disproportionately affected, and estimated figures suggest that more than 6 million elective orthopaedic procedures were cancelled worldwide during the first peak of the pandemic.
“Whilst these changes have served to ‘flatten the curve’ and reduce some of the harm associated with COVID-19 infection, there has undoubtedly been an impact on patients whose elective procedures were postponed,” said Luke Farrow, clinical research fellow at the University of Aberdeen and lead researcher on the study.
“COVID-19 has had a significant detrimental effect on access to hip and knee surgery, and work by others has suggested this has been associated with worsening pain and quality of life for patients. We were concerned that this may have been associated with greater rates of opioid prescribing to manage these symptoms.”
Opioids, such as morphine and tramadol, are often used as a last resort in pain management in osteoarthritis. However, there is growing evidence for limited benefit and even long-term detriment to health, especially in older adults.
Farrow said that he would “advocate” that healthcare professionals and patients avoid the use of opioid medication “if at all possible”.
“We urgently need to find better alternative methods for managing severe arthritis pain for those awaiting this type of surgery and work to recover the backlog of associated operative cancellations during COVID-19 to prevent more widespread opioid use.”
Cathy Stannard, a consultant in complex pain at NHS Gloucestershire clinical commissioning group, said that for patients prescribed opioids while waiting for an operation, clinicians must be aware that they will eventually need to support them as they come off them.
“The main message that should be promoted here is that clinicians who prescribe them for this indication should follow them up because they don’t always help arthritis, and if they don’t help, they should be stopped. But if they are helping, then it’s reasonable to be on these medicines in safe doses before an operation.
“There is some evidence that outcomes are worse for people who are on opioids pre-op, but that’s really confounded by looking at all those risk factors for opioids like difficult-to-manage chronic pain, lack of attention to people’s own health, depression — there are so many risk factors for people being on opioids that could [lead to] a poor outcome.”
Emma Davies, advanced pharmacy practitioner in pain management at Cwm Taf Morgannwg University Health Board in Wales, said the pandemic had “worsened” rather than created a problem.
“Obviously, [there is] the burden on the health service in terms of waiting lists — all were rising or already [long] prior to the pandemic. Secondly, it could be suggested there is an over-reliance on medical intervention — lifestyle changes, weight management, increasing activity etc. are hard and support can feel limited, [and these are] also not always a popular choice because results take time and are hard work, but may provide better outcomes in the long run.”