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Despite significant changes in prescribing habits over the past several years, we continue to find ourselves in the epicenter of the opioid crisis. While we saw some reductions in opioid-related deaths in 2018 and 2019, the number of overdose deaths continues to be unacceptably high with drug-related fatalities jumping 30% between April 2020 and April 2021.

Nearly 75% of those with opioid addiction in the last 20 years started with a prescription drug. Many began to abuse pain medications, such as oxycodone and hydrocodone, after receiving a legitimate prescription to manage pain after surgery. That is why we as an orthopedic community are focused on identifying effective post-surgical pain management strategies without primary reliance on opioid medications.

The good news is there is a growing body of evidence supporting the effectiveness of the use of multiple non-opioid medications and techniques, or multimodal analgesia, to manage pain, particularly after knee surgery and total knee replacement. In fact, recent studies demonstrate multimodal analgesia can actually improve pain scores and reduce negative side effects, compared to opioid-based treatments.

A multimodal approach enables us to customize the pain management program around a patient’s individual needs. In general, my preferred treatments include a combination of:

• Analgesic medications – Acetaminophen and ibuprofen for pain control, corticosteroids to reduce inflammation, and other medications to treat nerve pain.

• Local anesthetics – Utilization of a longer lasting nerve block, particularly for total knee replacement, to better manage pain immediately after surgery.

• Non-medication strategies – Regular use of ice machine to control pain and swelling. At St. Vincent Charity, our patients wake up from surgery with an automated ice machine covering the surgical area and are encouraged to use throughout their recovery. Massage, electrotherapy and acupuncture during surgery are proving as effective tools to assist with pain management.

In addition, I caution patients against the use of opioid medications prior to surgery. In addition to an increased risk of addiction, the body can develop a tolerance to the medications and increase one’s sensitivity to pain. Numerous studies show those who use opioids prior to total joint re-placement have worse outcomes, more difficulty controlling post-surgical pain, and are at an increased risk of infection and revision surgery. My rule of thumb to patients is if their pain cannot be controlled without opioid medication, then it is likely time for surgical treatment.

Effective pain management is critical to achieving the best results, particularly for total joint re-placement. Patients need to feel comfortable enough to quickly stand, walk, and participate in physical therapy to regain range of motion and mobility. The fear of post-surgical pain and the risk of opioids is often a cause for some to delay needed surgery. However, I find when patients learn they can undergo surgery without the risk of opioids and still have effective pain relief, they are excited and ready to move forward.


Dr. Matthew Levy writes about orthopedics for the Cleveland Jewish News. He is an orthopedic surgeon at St. Vincent Charity Medical Center and practices in Solon, Independence and downtown Cleveland.

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