Marc Darrow MD,JD

It is an unfortunate irony for some of the patients I see in our office that they had chosen to have a surgery, in part, to end their dependence on painkillers to help get themselves through the day. The sad irony of course is that after the surgery, many of these people are taking more painkillers. To be fair, not everyone who has a surgery uses more painkillers after the surgery, in fact, the majority of people can eliminate their need for painkillers if they have a successful surgery. This article will focus on those who use more painkillers after the surgery.

In this article I will discuss the new medical research surrounding concerns of painkiller (opioid) use pre and post joint replacement surgery.

Taking opioids before surgery increases risks

From Stanford University research: “Patients taking opioids (narcotic painkillers) prior to surgery experience prolonged postoperative opioid use, worse clinical outcomes, increased pain, and more postoperative complications.”(1) A follow up study from the same group of researchers comes something even worse: Patients presenting with preoperative opioid use have potentially an increased risk for opioid misuse after surgery. (2)

Patients who chronically use opioid medications prior to total knee replacement may be at a substantially greater risk for complications and painful prolonged recoveries.

Researchers in Canada (3) came to the same conclusion: Here is what they wrote in the American Journal of Bone and Joint Surgery:

  • “Chronic use of opioid medications may lead to dependence or hyperalgesia, (Opioid-induced hyperalgesia is an increased sensitivity to pain) both of which might adversely affect perioperative and postoperative pain management, rehabilitation, and clinical outcomes after total knee replacement.”

A significantly higher prevalence of complications was seen in the opioid group of knee replacement patients

Another study evaluated (4)  patients who underwent total knee replacement following six or more weeks of chronic opioid use for pain control and to compare them with a matched group who did not use opioids pre-operatively.

A significantly higher prevalence of complications was seen in the opioid group,

  • of the 49 knees replaced in this group –
    • 5 needed arthroscopic evaluations and
    • 8 needed revision surgery for persistent stiffness and/or pain, compared with none in the matched group.
    • Ten patients in the opioid group were referred for outpatient pain management, compared with one patient in the non-opioid group.

CONCLUSIONS: Patients who chronically use opioid medications prior to total knee replacement may be at a substantially greater risk for complications and painful prolonged recoveries. Alternative non-opioid pain medications and/or earlier referral to an orthopaedic surgeon prior to habitual opioid use should be considered for patients with painful degenerative disease of the knee.”

Patients with opioid use disorder have impaired immunity

Look at these learning points from a 2020 study in the Journal of primary care and community health. (5)

  • Prior opioid use was a very strong risk factor for future prior opioid use with an absolute risk increase of 61.6%.
  • One single dose of opioids has been shown to adversely alter sleep architecture and chronic opioid use can lead to the development of sleep apnea.
  • Opioid use is associated with greater severity and risk for depression
  • Surgery itself may be a risk factor for developing downstream comorbidities, (including autoimmune disorders) in part because of the required lifestyle changes and associated opioid use.

Painkillers after joint replacement causing more concerns

The problems of painkillers after joint replacement are a cause of heightened concern in the medical community:

In a paper from leading French researchers published in the European pain journal, the doctors wrote:

  • Despite the development of multimodal analgesia (many different pain medications) for postoperative pain management, opioids are still required for effective pain relief after knee replacement.(3)

Doctors at Mount Sinai in New York wrote in The Journal of the American Academy of Orthopaedic Surgeons

  • Total knee replacement is associated with substantial postoperative pain that may impair mobility, reduce the ability to participate in rehabilitation, lead to chronic pain, and reduce patient satisfaction. Traditional general anesthesia with postoperative epidural and patient-controlled opioid analgesia is associated with an undesirable adverse-effect profile, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and an increased infection rate.”(6)

In the latest study doctors found that many patients undergoing hip or knee replacement are still taking prescription opioid pain medications up to six months after surgery. The study that appeared in the medical journal PAIN was led by  Jenna Goesling, PhD, of the University of Michigan, the study identifies several “red flags” for persistent opioid use–particularly previous use of high-dose opioids. The results also suggest that some patients continue to use these potentially addictive pain medications despite improvement in their hip or knee pain.(7)

Concerns about Persistent Opioid Use after Joint Replacement

Dr. Goesling and her team analyzed patterns of opioid use in 574 patients undergoing knee or hip replacement surgery. Patients were followed up at one, three, and six months after surgery to assess rates of and risk factors for long-term opioid use.

  • About 30 percent of the patients were taking opioids prior to their joint replacement surgery. Of this group, 53 percent of knee-replacement patients and 35 percent of hip replacement patients were still taking opioids at six months after surgery.

Patients who were not taking opioids prior to surgery were less likely to report persistent opioid use: About 8 percent in the knee-replacement group and 4 percent in the hip-replacement group continued to take opioids at the six-month follow up. Although these are relatively small percentages, this suggests that a portion of patients who were “opioid naïve” prior to surgery will become new chronic opioid users following arthroplasty.

  • The strongest predictor of long-term opioid use was taking high-dose opioids before joint replacement surgery. For patients in the highest preoperative dose group (equivalent to more than 60 milligrams of oral morphine per day), the predicted probability of persistent opioid use at six months was 80 percent.
  • Among patients not previously taking opioids, those with higher pain scores the day of surgery–both in the affected joint and overall body pain–were more likely to report persistent opioid use at six months.
  • Opioid use was also more likely for patients who scored higher on a measure of pain catastrophizing–exaggerated responses and worries about pain–than those with depressive symptoms.

For all patients, reductions in overall body pain were associated with decreased odds of being on opioids at six months. However, improvement in knee or hip pain after joint replacement did not reduce the likelihood of long-term opioid use.

Persistent opioid use after knee or hip replacement surgery may be more common than previously reported, the new results suggest. Importantly, continued opioid use is not necessarily related to pain in the affected joint. “We hypothesize that the reasons patients continue to use opioids may be due to pain in other areas, self-medicating affective distress, and therapeutic opioid dependence,” the researchers write.(7)

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1. Hah JM, Sharifzadeh Y, Wang BM, Gillespie MJ, Goodman SB, Mackey SC, Carroll IR. Factors Associated with Opioid Use in a Cohort of Patients Presenting for Surgery. Pain Res Treat. 2015;2015:829696. doi: 10.1155/2015/829696. Epub 2015 Dec 31. PubMed PMID: 26881072; PubMed Central PMCID: PMC4736213.
2 Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg. 2017 Nov;125(5):1733-1740. doi: 10.1213/ANE.0000000000002458. PMID: 29049117; PMCID: PMC6119469.
3 Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. JBJS. 2011 Nov 2;93(21):1988-93.
4: Thomazeau J, Rouquette A, Martinez V, Rabuel C, Prince N, Laplanche JL, Nizard R, Bergmann JF, Perrot S, Lloret-Linares C. Acute pain Factors predictive of post-operative pain and opioid requirement in multimodal analgesia following knee replacement. Eur J Pain. 2015 Oct 30. doi: 10.1002/ejp.808.
5 Rhon DI, Snodgrass SJ, Cleland JA, Cook CE. The Risk of Prior Opioid Exposure on Future Opioid Use and Comorbidities in Individuals With Non-Acute Musculoskeletal Knee Pain. Journal of Primary Care & Community Health. 2020 Sep;11:2150132720957438.
Moucha CS, Weiser MC, Levin EJ. Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty.  J Am Acad Orthop Surg. 2016 Feb;24(2):60-73. doi: 10.5435/JAAOS-D-14-00259.
7 Goesling J, Moser SE, Zaidi B, Hassett AL, Hilliard P, Hallstrom B, Clauw DJ, Brummett CM. Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain. 2016 Jun;157(6):1259. 7