For those considering a hip replacement or knee replacement, pain is an unfortunate reality that often becomes the driver for scheduling joint replacement surgery. However, the road that stretches from joint discomfort all the way to “I can’t take it anymore” pre-surgery pain is long and complicated. Throughout this journey, you’ll likely try various treatments to keep pain from rearing its ugly head. However, not all pain treatments are created equal. Some doctor-prescribed pain medications, while they may temporarily close the door on pain, can open up a door you never expected: addiction.
We’ve all seen news headlines like “America’s Addiction to Opioids”, “Painkillers Kill” or most recently, “Prince’s Death Was Caused by Opioid Overdose”. Upon reading these headlines or even after diving into the story, it’s hard for many of us to imagine how out-of-control prescription med use (or should we say, abuse) can happen. Even more specifically, it may seem like a leap to link joint pain to a prescription pain medication addiction. Unfortunately, as reported in the media and the public healthcare industry alike, it's not a stretch.
Take for instance, the recent untimely death of Prince. Unlike Prince himself, his path toward addiction was unremarkable. Like many people living with joint pain, Prince (allegedly) began taking opioid prescription painkillers to combat his chronic hip pain. For religious reasons, Prince was unwilling to undergo the double hip replacement that would have likely resolved his pain for the long-term. Prince was left with one option- ongoing use of narcotics, which carries with it the slippery slope of tolerance building and physical dependency.
What Are Opioids and Why Can They Be Bad?
Opioids (also known as narcotics or “painkillers”) are a class of medications that are used to relieve moderate to severe chronic pain. Opioid medications include: hydrocodone (e.g. Vicodin), oxycodone (e.g. OxyContin, Percocet), morphine (e.g. Kadian, Avinza), codeine and fentanyl. These medications are highly addictive and much stronger than over-the-counter, NSAID pain relievers. Used correctly, opioid painkillers work really well. It’s the extra baggage that comes along with these medications that doesn’t.
Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report.
Since extreme pain can call for more extreme measures, opioids can weasel their way into long-term pain management plans. When taken for short-periods following doctor's instructions, these medications can be a safe and necessary treatment method for severe chronic pain. It’s when these meds are taken for a prolonged period, when the dosage is increased, or when taken close to a surgery date that you begin playing with fire. As Dr. Don Teater, MD and Medical Advisor with National Safety Council explains, “opioids should be avoided preoperatively prior to surgery. If surgery is a possibility in the future for individuals with back, knee, or other orthopaedic problems, acetaminophen with ibuprofen or other appropriate NSAID medications should be used rather than opioids for pain control.” In other words, if your pain is worsening and you've exhausted countless treatments, scheduling hip or knee replacement surgery is the ideal next step before hopping on the opioid pain train.
Why Are Opioids Dangerous?
78 Americans die every day from an opioid overdose. At least of half of these overdoses are from prescription drugs.
- They’re Very Addictive- A common a question from those being prescribed painkillers is “can I become addicted?” The answer: one million times, yes. According to the National Institute on Drug Abuse, approximately 2.1 million people in the United States and between 26.4 and 36 million people worldwide abuse opioids.
- Tolerance-Building- Just like alcohol and many other substances, the more opioid pain medication you take, the more you will need to take to feel an effect. Building an “immunity” or tolerance to narcotics can happen quickly, entering you into the danger zone faster than you may realize.
- Increased Hyperalgesia (Pain Tolerance) - Since opioids are strong pain relievers, you may find your body rid of pain while on these medications. This can lead to overexertion and cause greater damage to the troubled joint.
- Experience Withdrawal Symptoms- If you’ve taken opioids for a prolonged period and want to stop taking them, you may experience a varying range of physical withdrawal symptoms. Withdrawal symptoms indicate that your body has formed a dependency on the drugs. These symptoms will range from mild to severe depending on your use level. For those on heavy doses of painkillers, withdrawal can include: severe nausea, rapid heartbeat and high blood pressure. Here is a nationally accepted opioid withdrawal measurement scale.
- Accidental Overdose- Going hand-in-hand with tolerance-building, taking more than the prescribed dose of a narcotic can lead to an overdose. Overdoses can result in seizures, heart attack and death. 78 Americans die every day from an opioid overdose--at least half of which are from prescription opioids.
- They’re Over-Prescribed- Beyond the medication itself, there is a deep-seated issue in the way opioids are approached. In the last decade, prescription opioids have been over-prescribed by healthcare professionals making the medications readily available, harder to control, and more susceptible to abuse. A 2014 study in Academic Emergency Medicine, found that “between 2001 and 2010, the percentage of overall ED (emergency hospital) visits where any opioid analgesic was prescribed increased by 49.0%”.
In specific reference to an upcoming joint replacement, chronic pre-op opioid medication use has demonstrated to increase complications, the need for revision surgery, and even post-op pain. A study in The Journal of Bone & Joint Surgery looked at 49 patients who had regularly used opioid medications for pain control prior to total knee arthroplasty. This group was compared to patients who had not used opioids before surgery. The study found that “patients who chronically use opioid medications prior to total knee arthroplasty may be at a substantially greater risk for complications and painful prolonged recoveries.” Specifically, of the 49 chronic opioid-users, 8 of them had revisions for persistent stiffness/pain. Comparatively, no one had a revision in the matched, opioid-free group.
There are a host of reasons to avoid long term use of opioid painkillers. Although we are trying to instill some reality-based fear, it is ultimately up to you and your medical provider to come up with the best pain management plan for you. Our recommendation is that you have a healthy understanding of what “normal pain” for a pre-op joint replacement candidate is and that you test out all alternatives before filling an opioid prescription.
Understanding Your Pain: What is Normal?
Pain sucks. Unfortunately, “pain” and “joint replacement” are almost synonymous. It’s completely natural to want to reduce the amount of pain you’re in as much as possible, but it’s unnatural to think you can and should cut out pain entirely. Admittedly, you’re in a bit of a rock in a hard place, but it’s important to understand what normal levels of pain are for someone in your position.
McMaster University ran a patient perspective survey for total hip replacement (THA) and total knee replacement (TKA) patients. In the survey, the patient groups were asked to rate the severity of their preoperative hip or knee pain on a scale of 0 (no pain) to 10 (extreme pain). The THA group rated their pain a 7.9 out of 10 (mean). The TKA group rated their pain slightly higher at 8.2 out of 10. The same patients were asked to rate their pain post-op while still in the hospital. The total hip replacement and total knee replacement groups rated their pain levels at a 5.0 and 5.5 out of 10 respectively.
For a wide majority, joint replacement surgery provides unmatched pain relief. According to the Oxford Hip/Knee Pain Score that looked at 6376 primary knee and hip replacements from 1998 to 2007, 95.5% of THA patients reported having less pain 1 year after surgery than they did before surgery. Similarly, 86.4% of TKA replacements reported having less pain a year later.
Although everyone’s pain is different and uniquely their own, we hope that this scale can help you gage what typical pain levels look like for someone before a joint replacement. Also, know that pain throughout the recovery process is to be expected but that you can anticipate drastically reduced pain as more time passes.
Treating Joint Pain Without Opioids: Alternative Methods
Opioid medication should be used as a last resort to chronic joint pain. It’s our recommendation that you exhaust all alternative treatments available to you before speaking with your doctor about opioids or filling an opioid prescription. Here are some proven methods of pain relief that are relatively consequence-free.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These are the most commonly used medications for pain relief. These are the over-the-counter medications readily available in pharmacies, grocery store checkouts, gas stations etc. NSAIDs include: aspirin, ibuprofen (e.g. Motrin, Advil), naproxen (e.g. Aleve) and celecoxib (e.g. Celebrex). These medications contain no addictive properties and should be taken as directed.
Injecting systemic steroids into hip or knee problem areas can reduce inflammation and pain. These injections are given by your doctor and should not be received too frequently (no more than once every four months). They also should not be taken too closely before scheduled surgery (some surgeons recommend not within 6 months). Speak with your doctor or orthopaedic surgeon about their recommendation for you.
Although it may seem unintuitive, targeted exercises and movements can actually reduce your muscle and joint pain. Working with a physical therapist and taking part in a prehab will introduce you to low-impact exercises that can build muscle, flexibility and range of motion where it counts. Exercising in a monitored, safe environment (like a swimming pool) comes with a list of secondary benefits as well. For instance, water therapy offloads your body weight and allows you to perform at a higher intensity that would not be possible on land. Boosting your cardio can lead to weight loss, which can directly cut down on joint pain. As a study out of John Hopkins University suggests, “losing 15 pounds could alleviate knee pain in people with knee osteoarthritis by 50 percent.”
Like exercise, diet can help you shed the extra pounds that are affecting your knees or hips. After all, these joints are weight-bearing. For each pound you lose, you are relieving your knee joint load by a significant multiplication.. The exact relief to your knee is said to be anywhere between 4-9 pounds per pound lost. As such, that same 15 pounds means your knee joint is carrying 60-135 pounds less. In addition to unloading your joint, diet can actually be a powerful tool in your belt to combat pain, inflammation and joint stiffness.
Foods that are proven have pain-reducing properties:
- Omega-3s and fish oil supplements-Can reduce your joint stiffness and pain. Foods with sources of omega-3: mackerel, salmon fish oil, walnuts, chia seeds, wild salmon, flax seeds, tuna, egg yolks etc.
- Turmeric- This yellow curry spice, common in Indian dishes, is an anti-inflammatory said to reduce arthritic pain.
- Ginger- Can reduce pain, arthritic stiffness, and decrease joint inflammation.
- Cherries- "They block inflammation and they inhibit pain enzymes, just like aspirin, naproxen, and other nonsteroidal anti-inflammatories," says Muraleedharan Nair, PhD, natural products chemist at Michigan State University's College of Agricultural and Natural Resources. Did we mention they’re delicious too?
- Natural Herbs- Arnica, aquamin, basil, boswellia, bromelain, capsaicin, GLA (found in seed oils) and peppermint are proven to cut arthritic pain and more.
Always consult your healthcare practitioner before drastically changing your diet or starting a new supplement regime. Consult your doctor as your surgery date nears (1-2 weeks out) as changes will likely need to be made to your PreHab pre-surgical diet.
An unfortunate side effect of chronic pain is that even after a joint replacement resolves the problem, lasting anxiety about movement and putting pressure the problematic joint can slow down rehabilitation. Practicing mindfulness meditation is a proven means to reduce anxiety, increase pain tolerance and let go of “old” pain after surgery.
Joint Replacement Surgery
Joint replacement surgery is one of the most successful orthopaedic surgeries in modern medicine. The procedure, lasting around little more than one hour delivers an unprecedented long-term solution to osteoarthritis and knee and hip pain. As the Oxford Pain study found, 95.5% and 86.4% of hip replacement and knee replacement patients respectively reported reduced pain after the procedure. Although a total joint replacement is invasive and requires prehab as well as a rehab/recovery period, the lasting effects offer the most comprehensive answer to you joint pain.
Mirroring the same sentiment as Dr. Teater, The Journal of Bone & Joint Surgery study concluded by saying “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”. In other words, before heading down the slippery slope of prescription opioid use, try everything else. Joint replacement surgery is a long-term solution for your joint pain and is best taken advantage of as early as possible.
Contributed by Grace McClure