Opioid Sparing Pain Management in Orthopaedics

By: Shariff K. Bishai, D.O., M.S., DAL

As I drove down to Cincinnati, Ohio to have my rotator cuff repaired, the obvious concerns about having a procedure bounced around in my head. Being a surgeon, I was worried about a variety of things: How long would I be out of work? Would my shoulder keep hurting even after it was fixed? Would the tendon heal properly? What is the possibility for infection or a complication? And, perhaps the most daunting: Would I get addicted to narcotics?

A particularly concerning thought of mine was the need for opioids after surgery. Nearly 7% of patients that are prescribed an opioid will go on to long-term use or abuse.1,2 I chose to have a long-acting intrascalene block for surgery and go with the multimodal opioid-sparing approach, which involves simultaneously using a combination of greater than two analgesics that act at different sites within the central and peripheral nervous systems in an effort to reduce pain and minimize opioid use, in order to avoid narcotics.

Groggily, I shuffled back into the operating room and put my faith in my dear friend Dr. Paul Favorito to take care of my shoulder. Over the next three days, I took only one Norco oral tablet. As a result of my knowledge about the opioid epidemic, I was able to make an educated decision on my care. Unfortunately, this is not necessarily the case for many of the patients we treat. As surgeons and advocates for our patients, we need to be educators and guide them on making the best decisions possible.

Some background on opioids and orthopaedics: In the late '90s, "pain" became a vital sign. Traditionally, blood pressure, pulse, respiratory rate and body temperature were all common vital signs, which are objective. However, since pain is subjective with each person having a different pain threshold, the person could use the vital sign of pain as a barometer of outcome. This idea resulted in patients having an unrealistic expectation that the surgery was not going to be painful, and that they would be treated with narcotics to avoid any subsequent discomfort. "Pain relief" became synonymous with "patient satisfaction." With increased pain came decreased satisfaction. This was a slippery slope that led to a cascade of events, including an overprescribing of narcotic medications that resulted in addiction and the opioid epidemic that we are now reeling from.

The statistics related to opioids are staggering. To start, Orthopaedic Surgeons are the third largest prescribers of opioids among physicians3 – Huang and Copp found that pain pills were overprescribed by 34% in total knee arthroplasty and 140% in total hip arthroplasty.4 There’s a reason Orthopaedic Surgeons are one of the largest groups of opioid prescribers among physicians: The number of pills that are given patients, especially to the opiate-naïve patient, are incredible. In 2017, Michigan statistics showed that on average, patients received 82 narcotic pills after their surgery.5 In many of our own cases, it is convenient to make sure that our patients have enough pain medication so they will not be inconvenienced with increased pain and the possible need for emergency room or clinic visits. With that being said, the reality is there are several pills left over. This can lead to problems with the patient, their families or anyone, for that matter, who can get their hands on the extra pills. In many cases, it is the access to these pills which leads to abuse.

It is possible for patients to feel pain relief while taking fewer opioids thanks to opioid sparing techniques. The literature has shown quite a few advantages in using opioid sparing techniques in orthopaedics: Cho et al. randomized 70 patients into a multimodal group and an intravenous pain group after rotator cuff repair. They found statistically significant improvements in pain relief in the multimodal group on postoperative day zero, three, four and five, and functional recovery occurred earlier in the multimodal group. They also found less dizziness and urticaria in the multimodal group. There was no difference in nausea, vomiting, urinary retention or headache.6

Clarke et al. found the use of perioperative gabapentin reduced postoperative opioid consumption and lends itself to improved participation in physical therapy after total knee arthroplasty.7

Echard et al. had similar findings with a 25% reduction in opioid consumption in the first 48 hours postoperatively when adding dexamethasone and gabapentin dosing protocol.8 Additionally, Padilla and his group found that an opioid-sparing protocol reduced opioid consumption and provided equivalent pain management and patient-reported outcomes in the 90-day postoperative period following total hip arthroplasty.9

Multimodal opioid-sparing techniques do exist, and they do work. A technique which I have adopted includes the use of a long acting liposomal bupivacaine nerve block, anti-inflammatory medication, acetaminophen, a steroid, a nerve pill and cryotherapy. Of course, this comes with patient education and a discussion with the patient to manage expectations, which starts in the clinic. The days of "this works for me" need to end, and we need to rely more heavily on evidence-based medicine with opioid-sparing options to achieve the best outcome for our patients.

Over the last few years, we have made great strides in combating the opioid epidemic; however, there is still significantly more work that needs to be done. Physician education will lead to better patient interactions and treatment. We have a responsibility to our patients to continue learning and evolving as clinicians as well as doing our part to help turn the tide on this epidemic.

Configure: New ContentHtml


  1. Alam, A., Gomes, T., Zheng, H., Mamdani, M.M., Juurlink, D.N., Bell, C.M. "Long-Term Analgesic Use After Low-Risk Surgery: A Retrospective Cohort Study." Archives of Internal Medicine. 2012;172(5):425-430. doi:10.1001/archinternmed.2011.1827
  2. Carroll, I., Barelka, P., Wang, C.K., et al. "A Pilot Cohort Study of the Determinants of Longitudinal Opioid Use After Surgery." Anesthesia & Analgesia. 2012;115(3):694-702. doi:10.1213/ANE.0b013e31825c049f
  3. Volkow, N.D., McLellan, T.A., Cotto, J.H., Karithanom, M., Weiss, S.R. "Characteristics of Opioid Prescriptions in 2009." JAMA Internal Medicine. 2011;305(13):1299-1301. doi:10.1001/jama.2011.401
  4. Huang, P.S., Copp, S.N. "Oral Opioids Are Overprescribed in the Opiate-Naive Patient Undergoing Total Joint Arthroplasty." Journal of the American Academy of Orthopaedic Surgeons. 2019;27(15):e702-e708. doi:10.5435/JAAOS-D-18-00404
  5. "Exposing a Silent Gateway to Persistent Opioid Use – A Choices Matter Status Report." Plan Against Pain, October 2018.
  6. Cho, C.H., Song, K.S., Min, B.W., et al. "Multimodal Approach to Postoperative Pain Control in Patients Undergoing Rotator Cuff Repair." Knee Surgery, Sports Traumatology, Arthroscopy. 2011;19(10):1744-1748. doi:10.1007/s00167-010-1294-y
  7. Clarke, H., Pereira, S., Kennedy, D., et al. "Gabapentin Decreases Morphine Consumption and Improves Functional Recovery Following Total Knee Arthroplasty." Pain Research and Management. 2009;14(3):217-222. doi:10.1155/2009/930609
  8. Eckhard, L., Jones, T., Collins, J.E., Shrestha, S., Fitz, W. "Increased Postoperative Dexamethasone and Gabapentin Reduces Opioid Consumption After Total Knee Arthroplasty." Knee Surgery, Sports Traumatology, Arthroscopy. 2019;27(7):2167-2172. doi:10.1007/s00167-019-05449-8
  9. Padilla, J.A., Gabor, J.A., Schwarzkopf, R., Davidovitch, R.I. "A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes." Journal of Arthroplasty. 2019;34(11):2669-2675. doi:10.1016/j.arth.2019.06.038
Scroll to top