4 medications to control pain after surgery

More than 1 million people in the United States undergo a total hip or total knee replacement each year. Since both procedures typically involve weeks of pain and recovery, surgeons often prescribe medication to help relieve discomfort.

Historically, opioids were a primary choice for controlling pain. But in more recent years, a “multimodal” approach with other, non-opioid pain relievers has become widely used.

“While opioids definitely have a role during and immediately after surgery, some patients can begin to take too much and become dependent on the narcotic medication,” says Cameron Ledford, MD, an orthopedic surgeon in Jacksonville, Florida. “But if you rely on several other alternative forms of pain-relieving medications to help, you can significantly reduce the amount of opioids in both the short and long term.”

With that in mind, here are some ways a multimodal approach works to ease pain.

Medication before surgery

Pain relief begins well before surgery starts.

“We give patients several medications such as acetaminophen, anti-inflammatories, and gabapentin (a nerve pain medication) a few hours before surgery, while they are sitting in the preoperative room,” explains Ledford. “It’s thought that taking them before the operation can blunt or even prevent the inflammatory cascade and pain reaction that occurs after the soft tissue injury or surgery. As a result, it can help proactively reduce some of the pain.”

Medication during surgery

General anesthesia is used to put a person in a state of deep sleep during a medical procedure, so they don’t feel pain. For hip and knee surgery, rather than relying strictly on general anesthesia, “we like to utilize spinal and regional anesthesia, since they can reduce the amount of opioids required during the procedure,” says Ledford.

He also recommends some form of local anesthetic, which involves an injection around the surgical joint area to block pain.

Medication after surgery

There are several types of pain medication a healthcare provider (HCP) might consider for recovery. They include the following.

Over-the-counter (OTC) acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are pain-relief medications that include OTC options like ibuprofen and naproxen, as well as prescription drugs like meloxicam and diclofenac.

Acetaminophen and NSAIDs are often used together as first-line treatment for mild to moderate acute pain, says Ledford. Frequently, a patient is put on a schedule alternating use of one or the other every few hours. “They have a synergistic effect as both have different mechanisms of action,” explains Ledford. “The acetaminophen is a general pain reliever, while the NSAID is an anti-inflammatory.”

COX-2 inhibitors

COX-2 inhibitors are more selective forms of NSAIDs with potentially fewer side effects. These prescription medications work by blocking a specific enzyme, COX-2, which is responsible for making prostaglandins, chemicals that trigger inflammation or pain.

They can be used in place of the non-selective NSAID in an acetaminophen-NSAID combination. Generally, you alternate the use of a COX-2 inhibitor with acetaminophen.

Nerve pain medications

Drugs such as gabapentin (Neurontin) or pregabalin (Lyrica) can help calm neuropathic, or nerve-related, pain stemming from the surgery. “This isn’t something we routinely schedule, like acetaminophen and NSAIDs, but it’s there if patients need it,” says Ledford.

Opioids

If other medication options don’t effectively manage pain, HCPs commonly prescribe opioids.

Some patients will need to be on opioids for severe pain for a little while after surgery, explains Ledford, “but some won’t require them after that if they rely on the tiers of drugs described above.”

Opioids are not intended for long-term use after knee and hip surgery. To prevent dependence, HCPs typically prescribe the lowest effective dose and then, if needed, take care to wean patients off the drugs.

Staying as active as possible post-surgery

Before you leave the hospital, you’ll need to show you can do certain things such as getting in and out of bed alone and walking with an assistive device like a cane or walker.

“Ideally, you want to be standing and even taking a few steps the same day, after having your surgery,” says Ledford.

Once you’re home, it’s important to follow any prescribed exercises and to start physical therapy as soon as your surgeon tells you to.

“The more you get up and move safely within reason, the more you’ll start building muscle strength and endurance again,” adds Ledford.