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Medication can help you feel more comfortable, allowing you to:

• Start moving sooner
• Get your strength back more quickly
• Recover from surgery faster

Many types of medicines are available to help manage pain:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Opioids
• Local and regional anesthetics

NOTE: Opioid use after orthopaedic surgery has appropriate safety concerns and is considered only after alternative non-medication and non-opioid medication approaches are tried and not sufficient.  Surgeons and their patients increasingly choose non-medication methods such as ice/heat, hypnosis, and acupuncture as a supplement to conventional medicine. A combined, tailored approach to pain management often gives the best result.

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce swelling and soreness and are often used alone for mild to moderate pain. Some examples of NSAIDs include ibuprofen, naproxen, and celecoxib.

To manage the moderate to severe pain after surgery, NSAIDs are often used in combination with acetaminophen (e.g., Tylenol) and opioids as well as non-medication strategies for an optimal result.

How NSAIDs Work

NSAIDs work by preventing an enzyme (a protein that triggers changes in the body) from doing its job. The enzyme is called cyclooxygenase, or COX, and it has two forms:

• COX-1 protects the stomach lining from harsh acids and digestive chemicals. It also helps maintain kidney function.
• COX-2 is produced when your body is injured or inflamed.

Traditional NSAIDs block both COX-1 and COX-2; however, COX-2 specific NSAIDs are also available.

COX-1 and COX-2 enzymes play a key role in making prostaglandins, which cause pain and swelling by irritating your nerve endings. By blocking the COX enzymes — and, therefore, the production of prostaglandin —  NSAIDs essentially stop your body from making too much inflammation. This directly reduces your pain and swelling.

Advantages and Disadvantages of NSAIDs

• Like all medications, NSAIDs do have side effects, but they are typically minimal with less risk when compared to opioids.
• NSAIDs alone may not relieve the moderate to severe pain you may have after surgery. However, using NSAIDs may limit your need for opioid medications and, therefore, reduce common opioid side effects like constipation and drowsiness.
• NSAIDs typically do not lead to addiction or dependence. 
• As mentioned above, traditional NSAIDs like naproxen and ibuprofen block the actions of both COX-1 and COX-2 enzymes, which is why they can cause stomach upset and bleeding and are associated with ulcers.
• COX-2 specific inhibitors, like celecoxib, are a special category of NSAIDs. These medications target only the COX-2 enzyme that stimulates the inflammatory response. Because they do not block the actions of the COX-1 enzyme, these medications generally do not cause the kind of stomach problems associated with traditional NSAIDs. However, COX-2 inhibitors have possible cardiac side effects.

Acetaminophen

Acetaminophen does not interfere with the COX-1 or COX-2 enzyme to reduce pain, so it does not have anti-inflammatory properties. Scientists believe that acetaminophen relieves mild to moderate pain by elevating (raising) your body's overall pain threshold. It also lowers fevers by helping the body eliminate excess heat.

Used alone, acetaminophen works well for headaches, fever, and minor aches and pains, but it does not reduce the inflammation and swelling that might accompany a muscle sprain.

Like NSAIDs, acetaminophen may be used after surgery to reduce the amount of stronger opioid medications you need to control pain. Acetaminophen is also often combined with opioid tablets. When taken alone by mouth — in tablet form — opioids are not easily absorbed by the body. But when combined with acetaminophen, the opioid medication absorbs more easily and effectively.

Opioids are effective medicines used for moderate to severe pain. When taken as prescribed, they can be especially effective for managing short-term pain after surgery.

Individual doctors and medical facilities may have different policies, procedures, and pain control options available. In most cases after surgery, oral (PO), intramuscular (IM), or intravenous (IV) opioids will be prescribed. Doctors usually prefer to prescribe oral opioid medications for use when you return home.

Opioid Dependency

Be aware that although opioids help relieve pain after surgery or injury, they are narcotics and can be addictive. It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Talk to your doctor if your pain has not begun to improve within a few days of your treatment.

Since your surgeon can only estimate how much medication you will need, you may have opioids leftover after your full recovery. Unused opioids after surgery are a safety risk to you and those in your home.

The American Academy of Orthopaedic Surgeons (AAOS) strongly recommends that you return all UNUSED OPIOIDS to certified drop-off locations directed by your pharmacy.

Local anesthetics block pain in a targeted area of the body. In orthopaedic surgery, they may be used as anesthesia during a procedure, or as part of a pain management program after surgery.

The most commonly used local anesthetics include lidocaine, bupivacaine, and ropivacaine. These medicines work by blocking the pain signals that travel along the nerves to your brain.

For pain management, local anesthetics are given in a shot (or multiple shots) near your surgical incision, or as an epidural through a small tube in your back.

Local anesthetics do not cause the side effects of drowsiness, constipation, or breathing problems that you get with opioids.

Using local anesthetics carries the risk of a possible allergic reaction and may cause nerve damage, muscle spasms, and convulsions. For the most part, side effects can be avoided when you share your complete medical history with your doctor.

Regional anesthetics offer the advantage of providing anesthesia during surgery and pain relief for several hours afterward.

Medication is injected around the nerves in the part of your body where surgery is being performed. The medication can block feeling and movement:

• In the lower part of your body (spinal, epidural)
• In one of your arms (interscalene, supraclavicular)
• In one of your legs (femoral, sciatic)

Often, you can remain conscious (awake) during the procedure and require only light sedation. Other times, regional blocks may be used in addition to general anesthesia. Either way, you will have little or no pain when you wake up.  There is a risk of "rebound pain" when the block wears off and pain can increase dramatically.

Spinal and Epidural

Spinal and epidural anesthesia are neuraxial blocks. They block feeling and movement below the level at which they are given, typically the lower portion of the spine. They can numb the area from the lower abdomen and pelvis down to the toes.

• A spinal is given as a single injection of a local anesthetic or morphine directly into the spinal canal. Since it is only a single injection, its effect will last for the duration of the procedure but only a few hours afterward.
• Epidural anesthesia is given in the space around the spinal canal. The canal itself is protected by a lining membrane called the dura. The medication will pass through the dura and reach the spinal nerves. A small tube or catheter may be placed in the space around the dura and left in place for 1 or 2 days after surgery. Medication may then be given at various times through the catheter.

Epidural anesthesia often has less effect on the motor nerves than spinal and will allow for some function and mobility even when the catheter is in place.

In addition to orthopaedic procedures, epidural anesthesia is often given during childbirth.

• The most common side effects of giving opioids via the spine are nausea and severe itching.
• The most serious side effect is respiratory depression, which means that your breathing slows down and becomes shallow. Although this rarely happens, your surgical team will closely monitor you for several hours to prevent or address all side effects.

Learn more: Spinal Injections

Extremities

Regional anesthetics can be used to numb up a smaller area, such as your arm or leg.

In the upper extremity (shoulder to hand) the most common blocks are:

• Given at the base of the neck to numb up your shoulder and arm.
• Given above your collarbone to numb up your shoulder and arm.

In the lower extremity (hips to toes) the most common blocks are:

• Given in the groin area to numb the front of your thigh and knee.
• Given at the back of your knee to numb your lower leg, foot, and ankle.

As with an epidural, a catheter may be left in place following an interscalene, supraclavicular, or femoral nerve block. The epidural is used to provide pain relief for 24 to 48 hours after knee or shoulder surgery. It is then removed by the anesthesiologist.

Many anesthesiologists now use ultrasound technology to help guide placement of the needle or catheter before medication is injected around the nerves. An image on a monitor shows the nerves, muscles, arteries, and veins in the affected area. This allows the anesthesiologist to make sure the medication is injected into the right place.

Ultrasound is most commonly used for blocks involving the upper and lower extremities. Because it is not an X-ray, there is no radiation exposure from the procedure.

There are many different pain medications (opioids, NSAIDs, anesthetics) and different methods for giving them (injections, tablets, epidurals).

In orthopaedic surgery, there has been a recent trend toward combining different medicines with individualized delivery methods to produce the most effective pain relief in each patient. In addition to improved pain management, a combined approach can reduce opioid use and the side effects associated with it.

Doctors and researchers continue to investigate new combined pain management strategies to improve surgical recovery times and help patients return to their normal activities as quickly and safely as possible.

The American Academy of Orthopaedic Surgeons (AAOS) has conducted research to provide some useful guidelines that help manage each patient's pain after orthopaedic surgery. These are recommendations only and may not apply to every case. For more information: Pain Alleviation | American Academy of Orthopaedic Surgeons (aaos.org)