Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Orthopedic procedures are among the most painful in surgical practice and account for an estimated 7.7% of all opioid prescriptions in the United States (Soffin et al., 2017). With well-documented risks of opioid-related adverse drug events and long-term dependence, medicine has been experiencing a sustained shift toward multimodal, opioid-sparing analgesic strategies in perioperative care, including in the orthopedic context. However, non-opioid analgesia after orthopedic surgery is more challenging than in many other procedural settings due to the relatively high levels of postoperative pain.
Utilizing multimodal analgesia to reduce opioid use involves interrupting the pain pathway at multiple points—transduction at the site of tissue injury, transmission through peripheral nerves and the spinal cord, and perception in the brain (Trasolini et al., 2018). Rather than relying on a single systemic agent, multimodal regimens incorporate acetaminophen, NSAIDs or COX-2 inhibitors, regional anesthetic techniques, and adjuvants such as gabapentinoids or ketamine as appropriate, with each component acting through a distinct mechanism to produce a synergistic analgesic effect while minimizing the dose-dependent side effects of any one agent (Carter et al., 2020; Grossi, 2025).
Clinical evidence supports the efficacy of non-opioid postoperative analgesia across many contexts. Based on a meta-analysis across abdominal surgery, bunionectomy, and hysterectomy, intravenous meloxicam, an NSAID, lowered morphine consumption in most procedure categories (Carter et al., 2020).
Preoperative patient education, pre-emptive dosing of acetaminophen and COX-2 inhibitors, spinal or regional anesthesia, and intraoperative periarticular or wound injections of local anesthetic, ketorolac, and low-dose opioid have been reported to nearly eliminate the need for parenteral narcotics in total joint arthroplasty, reducing average length of stay from 5.2 days to just over one day and lowering rehabilitation facility discharge rates from 40% to 1% (Trasolini et al., 2018).
Orthopedic Enhanced Recovery After Surgery pathways with opioid-balanced multimodal protocols are associated with earlier ambulation, shorter hospital stays, and fewer postoperative complications across hip fracture, spine, and arthroplasty populations, although evidence directly comparing opioid-free and opioid-balanced strategies in orthopedics remains limited (Grossi, 2025).
These benefits must be weighed against the risks of non-opioid agents themselves. NSAIDs carry risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular events, particularly in older patients or those with pre-existing comorbidities, and patient selection and careful dosing remain important (Grossi, 2025). At the institutional level, reducing opioid reliance also requires attention to prescribing culture: standardized, procedure-specific discharge guidelines, mandatory prescriber education, and structured preoperative screening for opioid tolerance or substance use disorder have all been shown to meaningfully reduce excess opioid dispensing without compromising analgesia (Soffin et al., 2017).
Multimodal, non-opioid or low-opioid analgesia is effective and safer than opioid-predominant regimens for many orthopedic patients, provided that analgesia regimens take into account individual risks and comorbidities. It is also important that institutions pair clinical protocols with structural safeguards against opioid overprescribing.
References
- Carter JA, Black LK, Sharma D, Bhagnani T, Jahr JS. Efficacy of non-opioid analgesics to control postoperative pain: a network meta-analysis. BMC Anesthesiol. 2020;20:272. https://doi.org/10.1186/s12871-020-01147-y
- Grossi P. Enhanced Recovery After Surgery (ERAS) Protocols in Orthopaedic Surgery: Opioids or Not Opioids? J Pain Res. 2025;18:1683-1695. https://doi.org/10.2147/JPR.S496891
- Soffin EM, Waldman SA, Stack RJ, Liguori GA. An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery. Anesth Analg. 2017;125(5):1704-1713. https://doi.org/10.1213/ANE.0000000000002433
- Trasolini NA, McKnight B, Dorr LD. The opioid crisis and the orthopedic surgeon. J Arthroplasty. 2018. https://doi.org/10.1016/j.arth.2018.07.002