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Background and Aims Opioid-tolerant patients presenting for elective orthopedic surgery are at increased risk for various adverse outcomes and risk mitigation can be complex. In our high-volume orthopedic specialty hospital, we have pioneered intraoperative auricular acupuncture through the CHENG Protocol; this protocol is routinely employed by anesthesiologists. While preliminary data suggest promise in the CHENG protocol by enhancing multimodal analgesia via potentially reducing pain, stress, and inflammation, it is unclear to what extent these findings translate to high-risk groups such as patients who use opioids chronically before elective surgery.Methods We conducted a retrospective study using institutional data from January 2021 to March 2025, including 2,372 elective inpatient total hip arthroplasty (THA) surgery. Overall, 7.9% (n=187) were opioid-tolerant. Two groups were compared: those with acupuncture and without a peripheral nerve block (PNB) [Acu+PNB-], and those without acupuncture and with a PNB [Acu-PNB+]. The primary outcome was total opioid utilization in milligram morphine equivalents (MME) within 48 hours. Adjusted regression models measured associations between intervention groups and outcomes. These analyses were conducted separately for opioid-naïve and opioid-tolerant patients.Results Among opioid-naïve THA patients, 28.2% received auricular acupuncture without a peripheral nerve block (Acu+PNB−), while 71.8% received a nerve block without acupuncture (Acu−PNB+). Among opioid-tolerant patients, 18.2% were in the Acu+PNB− group and 81.8% in the Acu−PNB+ group. In adjusted analyses, opioid-naïve patients in the Acu+PNB− group had similar 48-hour opioid consumption (50.6 MME) compared to those in the Acu−PNB+ group (56.2 MME); p=0.051. However, among opioid-tolerant patients, those in the Acu+PNB− group had significantly lower 48-hour MME use (86.7 vs. 134.4; p=0.002).Conclusions Intraoperative auricular acupuncture using the CHENG protocol may reduce opioid use, specifically among high-risk patients and those on opioids preoperatively. Given the complexities associated with managing these high-risk patients, these findings warrant further investigation into this promising non-pharmacologic adjunct to standard care.