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If you are taking pain pills while you wait for surgery, this article is for you. Opioids before joint replacement can make your recovery harder, and the research on this is consistent. The good news is that it is a risk you can lower before your surgery date.
“Can you give me something for the pain until surgery?” It’s one of the most common questions I hear in clinic. I understand it. Arthritis pain wears people down.
But after more than twenty years and 700+ joint replacements a year, here’s what I tell my patients: the pill that gets you through the waiting period can work against you on the other side of surgery.
Should You Take Opioids Before Joint Replacement?
For most patients, no. The American Association of Hip and Knee Surgeons (AAHKS) advises that opioids should be avoided for arthritis pain and saved for exceptional situations.
Opioids do dull pain in the short term. The problem is what they do over weeks and months. Your body adjusts to them, and that adjustment follows you into the operating room.
Which Medicines Count as Opioids?
Opioids, also called narcotics, are strong prescription pain relievers. Common ones include:
- Oxycodone, including Percocet (oxycodone with acetaminophen)
- Hydrocodone, including Norco and Vicodin (hydrocodone with acetaminophen)
- Tramadol
- Morphine and hydromorphone (Dilaudid)
Tramadol surprises a lot of people. It is often thought of as a milder option, but it is still an opioid and it still counts.
How Common Is Opioid Use Before Hip or Knee Surgery?
Using opioids before joint replacement is very common. A study of 473,781 Medicare patients found that about 60 percent filled at least one opioid prescription in the 12 months before hip or knee replacement.
The same study found that use tended to rise as the surgery date got closer. That makes sense. Pain peaks right before surgery, and that is exactly when the pressure to reach for something stronger is highest.
How Do Opioids Before Surgery Affect Your Recovery?
Taking opioids before joint replacement is linked to more pain medicine afterward, more complications, and lower function scores. Each of these has been measured in hip and knee replacement patients.
More Pain Medicine After Surgery
In a study of 802 hip and knee replacement patients, those who took opioids before surgery were about 2.5 times more likely to still be taking them three months later. The more they used before surgery, the more they needed after.
A second study followed 574 patients for six months. Among knee replacement patients who used opioids beforehand, 53.5 percent were still on them at six months. Among those who had not, only 8.2 percent were.
Higher Complication Risk
The same 802-patient study found that prior opioid users were nearly twice as likely to have a complication during their hospital stay. They also stayed in the hospital longer.
In a smaller study of 49 knee replacement patients who took opioids regularly beforehand, eight needed revision surgery (a second operation to fix or replace the implant). A matched group that did not take opioids had none.
Lower Function Scores
A hip replacement study compared 54 prior opioid users with a matched group who did not use them. At about five years, the opioid group scored lower on a standard hip function test (84 versus 91 points out of 100).
Both groups still improved a great deal compared with before surgery. That point matters. Joint replacement helps people who have taken opioids; they simply tend to do less well than they could have.
Why Do Opioids Make Surgical Pain Harder to Control?
Opioids change how your nervous system handles pain. Two things happen over time.
- Tolerance: the same dose stops working as well, so it takes more medicine to get the same relief.
- Hyperalgesia: the body becomes more sensitive to pain overall. Research cited in one hip study suggests this can begin after as little as four weeks of daily use.
Put those together and you can see the problem. The usual medicines we give after surgery work less well, and the surgical pain itself can feel stronger. In my practice, that is the patient who has the hardest first two weeks.
Should I Stop Opioids Before Knee or Hip Replacement?
If you can safely reduce or stop them, yes. Clinical practice guidelines from AAHKS and other major orthopaedic groups recommend weaning off opioids before surgery when possible, with help from a pain management specialist.
How Do I Taper Off Opioids Before Joint Replacement?
Taper slowly, and only with the doctor who prescribes them. Stopping opioids suddenly can cause withdrawal (sweating, anxiety, stomach upset, trouble sleeping) and can be dangerous.
Here’s what I tell my patients about getting started:
- Tell your surgeon exactly what you take, how much, and how often. Include anything from other doctors.
- Talk with your prescriber about a step-by-step plan to lower the dose.
- Start early. A slow taper needs time, so bring this up as soon as surgery is on the calendar.
- Add nonopioid pain relief while you taper, so you are not left with nothing.
Be honest with your care team. Tennessee, like most states, has a prescription monitoring database that doctors check, and the goal is to build a safe plan together, not to judge anyone.
What If I Can’t Stop Completely?
You can still have surgery. Some patients take opioids for other long-term pain, such as back problems. In those cases, the surgeon and the pain management doctor plan together so your pain is covered after surgery.
Even partial progress helps. In the hip study above, 81 percent of patients who were taking opioids before surgery were off them by their last follow-up visit.
What Can I Take for Arthritis Pain While Waiting for Surgery?
Most patients can manage the waiting period with a mix of nonopioid options. These include:
- Anti-inflammatory medicines (NSAIDs) such as ibuprofen, naproxen, meloxicam, or celecoxib, if your doctor says they are safe for your kidneys, stomach, and heart
- Acetaminophen (Tylenol), taken on a schedule within safe daily limits
- Joint injections, such as a steroid injection, when timed safely before surgery
- Physical therapy and a home exercise program to keep the muscles around the joint strong
- Ice, rest, and activity changes on bad days, plus weight loss when it applies
One caution: many prescription pain pills already contain acetaminophen. Taking extra Tylenol on top of them can push you past a safe dose, so check labels and ask your pharmacist.
Our nonsurgical joint pain treatment page covers these options in more detail. And after surgery, a nonopioid pain treatment plan lets most patients recover with little or no narcotic medicine.
Who Is at Higher Risk of Long-Term Opioid Use After Surgery?
Patients who took opioids before surgery carry the highest risk. Other factors that raise it include:
- Long-standing back pain or another chronic pain condition
- Depression, anxiety, or other mental health conditions
- A past history of substance use
None of these rule out surgery. They simply tell us to plan pain control more carefully and bring in the right specialists early.
When Should You Talk to Your Surgeon About Pain Medication?
Bring it up at your very first visit. Pain control is part of surgical planning, the same as blood work or implant choice.
Call your surgeon’s office sooner if:
- Your pain is climbing and your current plan is no longer working
- You find yourself taking more pills than prescribed
- Another doctor has started or changed an opioid prescription
- You have withdrawal symptoms while cutting back
If you are getting ready for a total knee replacement or a total hip replacement, our free knee replacement guide and hip replacement guide walk you through the weeks before surgery step by step.
Planning Joint Replacement in Franklin, Nashville, and Middle Tennessee
I see patients from Franklin, Nashville, Brentwood, Columbia, and across Middle Tennessee. Many arrive already taking opioids before joint replacement, and that is never a reason to feel embarrassed. It is simply part of the plan we build together.
If you are thinking about hip or knee replacement and have questions about the medicines you take now, let’s talk. You can schedule a consultation or call (615) 791-2630. The Bone and Joint Institute of Tennessee is located at 3000 Edward Curd Lane, Franklin, TN 37067.
This article is for educational purposes only and does not replace professional medical advice. Do not stop or change any prescribed medicine without talking to the doctor who prescribed it. Individual results may vary.
If you or someone you know is struggling with opioid use, the SAMHSA National Helpline is free and confidential, 24 hours a day, at 1-800-662-4357. In an emergency, call 911.
References
- Jin Y, Solomon DH, Franklin PD, et al. Patterns of prescription opioid use before total hip and knee replacement among US Medicare enrollees. Osteoarthritis Cartilage. 2019;27(10):1445-1453. doi:10.1016/j.joca.2019.05.023
- Goesling J, Moser SE, Zaidi B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157(6):1259-1265. doi:10.1097/j.pain.0000000000000516
- Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee GC. Preoperative opiate use independently predicts narcotic consumption and complications after total joint arthroplasty. J Arthroplasty. 2017;32(9):2658-2662. doi:10.1016/j.arth.2017.04.002
- Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011;93(21):1988-1993. doi:10.2106/JBJS.J.01473
- Pivec R, Issa K, Naziri Q, Kapadia BH, Bonutti PM, Mont MA. Opioid use prior to total hip arthroplasty leads to worse clinical outcomes. Int Orthop. 2014;38(6):1159-1165. doi:10.1007/s00264-014-2298-x
- Hannon CP, Fillingham YA, Nam D, et al. Opioids in total joint arthroplasty: the clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty. 2020;35(10):2709-2714. doi:10.1016/j.arth.2020.05.034
