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Preventing Chronic Opioid Use After Surgery

Surgeons need to manage a patient’s pain after surgery, and opioid medications have long been part of that. One challenge is that surgical pain managed by opioids increases the risk of chronic opioid use.

Of course, the healthcare industry has been working on better ways to balance the patient’s need for effective pain control and society’s need for preventing overuse and addiction. Never ignore a doctor’s prescription. If there are any sort of concerns, always discuss those concerns and alternatives and reach an agreement with your doctor about the best medication regimen for you.

Rates of Chronic Opioid Use After Surgery

Opioid use carries well recognized risks of morbidity, mortality, and disability.2 Among patients who had been prescribed opioids previously, chronic opioid use after a total knee replacement has been measured as high as 53%.3 This number published in 2016 may be on the decline considering concerns recently raised about opioid use. For patients who have never been prescribed opioids before, across various reports and procedures, chronic opioid use has ranged from 1% to 44%. 

Pre- and Post-surgical Physiotherapy Reduce Opioid Use After Surgery

One of the solutions easily available is better utilization of outpatient physiotherapy. This was demonstrated in a first-of-its-kind study recently published in the Journal of the American Medical Association.5 Kosaku Aoyagi, PT, PhD, of Boston University School of Medicine, and his colleagues conducted a retrospective review of Medicare records for 63,322 patients with total knee replacements (TKRs). The measured outcome was chronic opioid use. Not only does this reflect patient risks and societal cost, but it also helps us understand which procedures do a better job of reducing pain and improving recovery. Patients reliably receive inpatient rehab following a TKR. Therefore, the researchers focused on outpatient TKR, where usage is more variable. Here’s what they found.

  • Before: Outpatient physiotherapy before a TKR surgery improves results up to 25%
  • After: Outpatient physiotherapy after a TKR surgery improves results up to 25%
  • More: More outpatient physiotherapy after a TKR is better. They grouped patients as receiving 1 – 5 sessions, 6 – 12, or ≥ 13 sessions. Greater than 13 physiotherapy sessions was associated with the best outcomes – up to a 29% improvement.
  • Earlier: Earlier outpatient physiotherapy is better. They grouped patients by when their outpatient physiotherapy began: 0 - 30 days, 31 – 60 days, and 61 – 90 days. The earliest outpatient physiotherapy group saw improvements of up to 45%.

The current study adds to the results of previous studies showing that, following a TKR, a greater number of physiotherapy sessions as well as earlier initiation results in better outcomes in terms of pain and function.6-7


  1. Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic. Anesthesia and Analgesia. 2017 Nov;125(5):1733.
  2. Pizzi LT, Toner R, Foley K, Thomson E, Chow W, Kim M, Couto J, Royo M, Viscusi E. Relationship between potential Opioid‐Related adverse effects and hospital length of stay in patients receiving opioids after orthopedic surgery. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2012 Jun;32(6):502-14.
  3. Goesling J, Moser SE, Zaidi B, Hassett AL, Hilliard P, Hallstrom B, Clauw DJ, Brummett CM. Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain. 2016 Jun;157(6):1259.
  4. Lawal OD, Gold J, Murthy A, Ruchi R, Bavry E, Hume AL, Lewkowitz AK, Brothers T, Wen X. Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis. JAMA Network Open. 2020 Jun 1;3(6):e207367-.
  5. Aoyagi K, Neogi T, Peloquin C, et al. Association of physical therapy interventions with long-term opioid use after total knee replacement. JAMA Network Open. 2021; 4(10):e2131271.
  6. Pua YH, Seah FT, Poon CL, Tan JM, Liaw JC, Chong HC. Association between rehabilitation attendance and physical function following discharge after total knee arthroplasty: prospective cohort study. Osteoarthritis and Cartilage. 2017 Apr 1;25(4):462-9.
  7. Brennan GP, Fritz JM, Houck LK, Hunter SJ. Outpatient rehabilitation care process factors and clinical outcomes among patients discharged home following unilateral total knee arthroplasty. The Journal of Arthroplasty. 2015 May 1;30(5):885-90.
  8. Liebs TR, Herzberg W, Rüther W, Haasters J, Russlies M, Hassenpflug J, Project MA. Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. Archives of Physical Medicine and Rehabilitation. 2012 Feb 1;93(2):192-9.

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