Managing Pain from Total Joint Arthroplasty in an Opioid Epidemic
Opioids – given in high doses intravenously, intramuscularly, via a patient-controlled analgesia pump, and orally – have traditionally been the mainstay of pain management for total joint arthroplasty patients. Orthopaedic surgeons, in fact, have been among the top prescribers of opioids. 
But significant adverse effects of opioids have been shown to increase costs, length of stay, and readmissions,  not to mention the physical toll side effects like nausea, vomiting, and constipation can take on a patient recovering from joint replacement surgery. Recent studies in the orthopaedic literature have shown that opioid use is associated with worse outcomes and chronic postoperative use. [3-5]
And now, the US is in the grip of an opioid epidemic, with 115 people dying every day after overdosing on opioids. 
What are orthopaedic surgeons to do now, in the face of this crisis? How can they balance management of surgical pain with reduction of opioid usage?
One answer is multimodal pain management, said James D. Slover, MD, from NYU Langone Health in New York, at the recent ICJR East ISK Hip & Knee Course.
The concept of multimodal pain management – using more than 1 method or modality of controlling pain for the additive effects, for reduction of side effects, or for both  – has been gaining momentum for about a decade, and it seems to be working. A study by Memtsoudis et al  found that total hip and total knee arthroplasty patients who received multimodal pain management had an 18.5% decrease in opioid prescriptions after surgery.
Overall, healthcare providers have been writing fewer opioid prescriptions. A study from the Centers for Disease Control and Prevention  found that although the rate of opioid prescriptions per 100 persons increased annually in 2006 through 2010, it decreased 1.6% annually from 2010 to 2014 and then dropped 8.2% annually until 2017, for an overall relative reduction of 19.2% from 2006 to 2017. What’s more, the percentage of high-dose opioid prescriptions (≥ 90 morphine milligram equivalents/day) declined from 15.9% in 2006 to 8.5% in 2017. 
At the ICJR East ISK Hip & Knee Course, Dr. Slover shared the current pathway for multimodal pain management in joint replacement patients at his institution, noting that he and his colleagues continue to refine this pathway based on experience and new evidence in the literature.
- Narcotics taper
- Continue non-steroidal anti-inflammatory drugs (NSAIDs)
- Discuss postoperative protocol with patients
Day Before Surgery
- 1 gram of oral acetaminophen every 8 hours (3 grams total)
- Continue NSAIDs
- 81 mg of aspirin (part of the venous thromboembolism [VTE] prophylaxis pathway)
- Hydration protocol
Immediately Preoperative Period
- 5 mg to 15 mg meloxicam
- 10 mg of intravenous (IV) dexamethasone
- Periarticular injection with 0.25% bupivacaine and 40 mL epinephrine plus liposomal bupivacaine
- Reduced use of tourniquet for total knee arthroplasty patients
- Markedly decreased use of blocks and catheters
- 25 mg of IV fentanyl if the patient rates pain above 6
- IV ketorolac if the patient rates pain from 4 to 6
- Ice if the patient rates pain from 0 to 3
- 1 gram of IV acetaminophen every 8 hours for 1 day
- 7.5 to 15 mg of oral meloxicam each day
- 50 mg of oral pregabalin every 8 hours as needed for pain
- Aspirin as part of VTE prophylaxis
- Oral oxycodone for breakthrough pain only
- Tramadol for breakthrough pain in total hip arthroplasty patients
- Oxycodone and/or tramadol for breakthrough pain in total knee arthroplasty patients
Click the image above to hear more from Dr. Slover about managing pain in total joint arthroplasty patients during an opioid epidemic.
Dr. Slover has disclosed that he is a paid speaker for Pacira Pharmaceuticals.
- Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA. 2011 Apr 6;305(13):1299-301. doi: 10.1001/jama.2011.401.
- Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27(1):62-70. doi: 10.3109/15360288.2012.751956. Epub 2013 Jan 9.
- Nguyen LC, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty. 2016;31(9 Suppl):282-7. doi: 10.1016/j.arth.2016.01.068. Epub 2016 Mar 17.
- Kim KY, Anoushiravani AA, Chen KK, Roof M, Long WJ, Schwarzkopf R. Preoperative chronic opioid users in total knee arthroplasty-which patients persistently abuse opiates following surgery? J Arthroplasty. 2018;33(1):107-112. doi: 10.1016/j.arth.2017.07.041. Epub 2017 Aug 3.
- Cancienne JM, Patel KJ, Browne JA, Werner BC. Narcotic use and total knee arthroplasty. J Arthroplasty. 2018;33(1):113-118. doi: 10.1016/j.arth.2017.08.006. Epub 2017 Aug 17.
- CDC/NCHS, National Vital Statistics System, Mortality. CDC Wonder, Atlanta, GA: US Department of Health and Human Services, CDC; 2017.
- Hebl JR, Dilger JA, Byer DE, et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008 Nov-Dec;33(6):510-7.
- Memtsoudis SG, Poeran J, Zuizarreta N, et al. Association of multimodal pain management strategies with perioperative outcomes and resource utilization: a population-based study. Anesthesiology. 2018;128(5):891-902. doi:10.1097/ALN.0000000000002132.
- Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risk and Outcome – United States. Surveillance Special Report 2. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018.