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Post-operative pain is to be expected after joint replacement surgery, but with proper pain management, a level of tolerable discomfort is an achievable goal. If you are having a knee or hip replacement, chances are, you already understand the limiting effects of pain, and the pros and cons of pain medicine.
As the science of pain management grew during the 1980’s, we learned that giving pain medication on a 24-hour dosing schedule improved patient outcomes. However, this often meant waking up sleeping patients. Most nurses were hesitant to awaken patients as the common thinking was that a “sleeping patient is a pain-free patient.”
It is no longer believed that a sleeping patient is a pain-free patient, or that you should only take pain killers when the pain is severe. This is outdated information.
Also outdated is information regarding the risks of addiction associated with the use of pain medicines. Many patients are so worried about becoming addicted, they often under-dose themselves, despite the encouragement of their caretakers to take their analgesic medicine in a proactive manner.
Many patients will wait until their pain has become moderate to severe before asking for an "as needed" immediate-release opioid. Once requested, it may take a significant amount of time before the patient actually gets their medication. It can then take an additional 45 minutes for the body to absorb the medicine, and reach an effective blood level that will provide relief. By this time, many patients are already experiencing intolerable levels of pain.
Pain and Rehabilitation
The rehabilitation phase is a make or break window of time for restoring range of motion to patients' new joint replacements. If a patient's knee or hip cannot be aggressively ranged during rehab, they may never recover full range of motion. However, these kinds of exercises are most often very painful.
Uncontrolled pain has the capacity to undermine the rehabilitation process. Effectively managed pain allows patients to greatly benefit from rehabilitation services. With better pain management, patients are able to continue to progress with their rehab and reach their rehabilitation goals sooner than patients with poor pain control.
What Are Opioid Analagesics?
Opioids are one type of pain medicine such as codeine; another type is non-opioids which include medicines like acetaminophen (Tylenol®) and ibuprofen (Motrin®). Non-opioids are generally used to treat mild pain, whereas opioid analgesics are used to treat moderate to severe pain.
Like all medicines, only the person who is prescribed opioids should take them. They should be kept in a safe place where children and others cannot reach them. Opioids may be given by mouth, by injection into the muscle, vein, or spine, or by other methods. The most common and convenient way to take opioids is by mouth.
How Long Does Pain Relief From an Opioid Analgesic Last?
Opioids may be short-acting or long-acting. Short-acting opioids are sometimes called immediate-release. These opioids usually have an effect within an hour and relieve pain for about 4 hours. Short-acting opioids are usually taken when pain lasts only a few days.
Some short-acting opioid medicines contain the opioid alone while others contain a combination of an opioid and a non-opioid, often acetaminophen (such as Tylenol®).
When an opioid analgesic is combined with acetaminophen, the total dose of acetaminophen taken in one day should not be more than 4000 mg. People who have liver disease or drink alcohol heavily should take even less acetaminophen. Be alert and keep an eye on how much acetaminophen is in your medicine. This includes both prescribed medicine and other over-the-counter (OTC) medications such as cold or sinus remedies.
Long-acting forms of opioids are sometimes called controlled-release or extended-release. This means the medicine is gradually released into the body over an 8 to 12 hour period or longer. Long-acting opioids are usually used for chronic pain that lasts most of the day. They are taken at regularly scheduled times, such as every 12 hours. In addition, a short-acting pain medicine is usually prescribed at the same time, with instruction to take a dose as needed should the pain temporarily increase.
Examples of oral long-acting opioids:
- Morphine (such as Oramorph® tablets, MS Contin® tablets, or Avinza® capsules)
- Oxycodone (such as OxyContin® tablets)
How Much and How Often Should I Take My Pain Medication
Keep on top of your pain—don’t wait until pain becomes severe to take your medicine. Pain is easier to control before it reaches full force. Set a goal with your doctor or nurse for pain relief that makes it easy for you to sleep at night and to do your daily activities.
Plan a schedule with your doctor or nurse that provides enough pain medicine to keep you comfortable and that is timed to prevent you from becoming uncomfortable from pain. Only you and your doctor or nurse can determine the proper dosing schedule for your pain.
What Should I Know About Opioids and Addiction?
Patients and their loved ones are more concerned now than ever before about addiction. Many patients are misinformed regarding the risk of addiction associated with the use of opioid medicines and under-dose themselves despite the encouragement of their caretakers to utilize their analgesics in an anticipatory and proactive fashion.
You or your family may have questions about addiction. It is important to understand what addiction is. Addiction IS a chronic brain disease that can occur in some people exposed to certain substances such as alcohol, cocaine, and opioids. Taking opioids for pain relief is not addiction. People addicted to opioids crave the opioid and use it regularly for reasons other than pain relief.
Addiction IS NOT when a person develops "withdrawal" (such as abdominal cramping or sweating) after the medicine is stopped quickly or the dose is reduced by a large amount. If necessary, your doctor will avoid stopping your medication suddenly by slowly reducing the amount of opioid you take before the medicine is completely stopped.
Addiction also IS NOT what happens when some people taking opioids need to take a higher dose after a period of time in order for it to continue to relieve their pain. This normal "tolerance" to opioid medications doesn't affect everyone who takes them and does not, by itself, imply addiction. If tolerance does occur, it does not mean you will "run out" of pain relief. Your dose can be adjusted or another medicine can be prescribed.
Some Common Questions You May Have Are:
Is it wrong to take opioids for pain?
No! Pain relief is an important medical reason to take opioids as prescribed by your doctor. Addicts take opioids for other reasons, such as unbearable emotional problems. Taking opioids as prescribed for pain relief is not addiction.
Ask yourself: Would I want to take this medicine if my pain went away? If you answer no, you are taking opioids for the right reasons—to relieve your pain and improve your function. You are not addicted.
Should I “Tough it Out” and Try to Manage With Less Pain Medicine?
No! Many patients wait until their pain has become moderate to severe before requesting an "as needed" immediate-release opioid. Once requested, significant time may elapse before the patient is provided with the medication. An additional 45 minutes is required for enteral absorption before therapeutic serum levels are achieved. Too often, by the time patients experience relief, their pain has increased to a level that interferes with function and engenders anxiety.
What Can I Do About Side Effects?
Talk to your doctor, nurse, or pharmacist about the side effects of opioids. If they occur, remember that most opioid side effects can be treated or prevented.
Constipation
Constipation from opioids is very common, but it can be prevented. If it does occur, it can be treated.
Prevention is the best approach. If you take opioids daily, you need to eat more fiber and drink more liquids than you usually do. Many people also need to take a laxative. The most common type is a combination of stool softener and mild stimulant laxative. Those that can be purchased without a prescription include Peri-Colace® capsules or syrup and Senokot-S® tablets. Ask your pharmacist about less expensive generic forms.
Upset Stomach, Nausea, or Vomiting
This does not always occur, but if it does, it can be treated. Ask your doctor, nurse, or pharmacist for medicine to relieve this. After a few days, the nausea usually stops.
- Try sitting still and breathing slowly through your mouth. Nausea medicines that you can buy without a prescription include Dramamine® tablets and Emetrol® oral solution.
- If your pain is under good control, you may be able to reduce the nausea by taking a lower dose of opioid.
Drowsiness (sleepiness)
Some degree of sleepiness would be normal when you start taking an opioid, but after a few days the drowsiness usually goes away.
Other instructions you may receive from your doctor or nurse:
- Take the next dose before the last dose wears off. If pain is present most of the day and night, the pain medicine maybe taken at regularly scheduled times. If you are taking a short-acting opioid, this usually means taking it every 4 hours. You may need to set your alarm, especially at night, to be sure you take your dose before the pain returns and wakes you up.
- If your pain comes and goes, take your pain medicine when pain first begins, before it becomes severe.
- If you are taking a long-acting opioid, you may only need to take it every 8 to 12 hours, but you may also need to take a short-acting opioid in between for any increase in pain.
- If you take an opioid regularly for longer than a week, don’t suddenly stop taking it. When your therapy is complete, your doctor will slowly decrease your dose safely. If you need to take more or less pain medicine than planned, contact your doctor to get the plan changed.
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