By now everyone is aware of the opioid crisis in America. In 2019, nearly 50,000 people in the United States died from opioid-involved overdoses. Opioid pain medications, which are often legitimately prescribed by a physician following an injury or surgery, can quickly become addictive and turn into a dangerous drug habit for some patients. People who undergo knee replacement surgery (and other surgical procedures) do experience pain during recovery and need effective options to minimize the pain while healing.
Surgeons and nurses at University of Utah Health are looking for ways to reduce pain medication usage after knee replacement. Jan Hinich, a University of Utah Health nurse with a master's degree in public health nursing, is focused on reducing opioid usage.
The Dangers of Opioid Addiction
According to the U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), in 2019:
- More than 10 million people misused prescription opioids
- 50,000 people used heroin for the first time, and about 80% of first-time heroin users previously abused pain medications
- 49,860 people died from opioid drug overdose
Understanding how opioid pain medications work
While millions of people take pain medication each year, few understand how these medications work in your body. That's something Hinich is actively trying to change by educating patients.
Inside your brain there is a small area that receives pain signals. These signals alert your body that something is wrong so you can stop doing it—for example, feeling pain when you touch something hot so you can pull your hand away—or so your body can take steps to heal. "Opiate pain medications block these pain receptors," Hinich said. "They are not fixing anything, just making it so your brain doesn't get the signal."
Once patients understand that opioid medications are not helpful in the healing process and are only meant to be temporary, many can successfully moderate opioid usage. They may also switch to safer over-the-counter products like Tylenol or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.
Strategies to reduce pain after knee surgery without opioids
Hinich and others at U of U Health are working on multiple strategies to reduce opioid pain medication usage.
Creating better tools for measuring pain
Asking patients to quantify pain on the Numerical Rating Scale (NRS) of 0 to 10 is not scientific, which makes it harder to create effective treatment plans and avoid overprescribing opioids. U of U Health developed a better way to measure pain. Providers discuss pain and how it's impacting quality of life with the patient, then input that information into a Clinically Aligned Pain Assessment tool (CAPA). The tool analyzes the data and offers recommendations for an effective treatment plan.
While developing the tool, researchers studied more than 12,000 pain assessments and found that nurses and patients all preferred CAPA over NRS. The tool accurately identified pain severity and offered effective treatment 81% of the time, compared to just 42% of the time with NRS.
Setting realistic expectations
Recovery after a knee replacement is difficult and long. Pain can last for several weeks, and swelling can continue for up to six months after the operation. But it's normal to have some pain. When orthopedic surgeons set that expectation from the start, many patients understand they only need pain medications for a short time, immediately after surgery, when the pain is most intense.
Hinich is also educating physicians about using mindfulness after surgery. After she fell off a ladder and broke her back, she started reviewing studies on how mindfulness can reduce pain. Now she works with Adam Hanley, MD, an assistant professor in the College of Social Work whose research covers mechanisms of mindfulness interventions to treat addiction and pain.
"Mindfulness is the awareness of what you are thinking, feeling, and perceiving in the present moment, without judging it or reacting negatively to it," Hanley said. "It's like a mental push-up—each time you practice it, you are strengthening your mindfulness."
Mindfulness practices can range from formal (focused breathing, yoga, Tai Chi) to informal practice of simply being more aware of what is happening in the moment. Pain is complex, Hanley says, because we experience it two ways:
- Physical sensations: unpleasant physical feelings when the brain interprets damage signals from the body
- Psychological suffering: distress people sometimes experience because of unpleasant sensations
By using mindfulness techniques, people can manage both the physical and psychological aspects of pain. Physically, it helps close "pain gates" that transmit signals from the nervous system to the brain. Psychologically, it helps people either focus intently on a small aspect of the pain (zooming in) or focus broadly on your body and things outside of your body (zooming out) to diminish pain.
Utilizing physical therapy
Another effective option to reduce pain is physical therapy (PT). One study showed that PT interventions before and after a total knee replacement reduce the risk of long-term opioid use. PT may also be an option for patients with chronic pain who are taking opioid medications regularly and want to reduce their dependence.