I started using a limited narcotic approach for my joint replacements in 2008. Prior to that time, like all other joint replacement surgeons, I was administering conventional narcotic pain management, which entailed significant side effects. 

Patients reported fatigue, nausea, constipation, itching and poor sleep. All are well known effects of narcotics. Also, it was difficult to wean the patients from these drugs once they began taking them. Medical literature and news reports at the time were replete with stories of patient dependence on these drugs. 

Non-Narcotic Joint Replacement  Surgery

Happily, it was around this same time that researchers were measuring the effectiveness of non-narcotic oral agents, non-steroidal drugs, and other agents, many of which were found to be more effective than narcotics when administered before surgery, and bolstered by intraoperative injections.

By 2015 I was significantly limiting, if not entirely eliminating, narcotics. Patient trial groups were reporting amazing results. All but one member of my first trial group, which consisted of 20 elderly individuals, went home the day after surgery.

Then, our average length of stay with narcotic pain relief was three days.

To verify what I'd been hearing, I began visiting all my patients at home. I found that all of them were mobile in their homes. A number of them were busy caring for their elderly spouses! 

Why did this work so well? First, having a blood level of the pain management medicines provide what doctors call preemptive pain relief. This means that before the pain stimulus is perceived by the patient, the brain and spinal cord are medicated to manage the pain stimulus. 

This however is just the beginning of the non-narcotic approach. During surgery I anesthetize every tissue before I handle it surgically. For example, the skin is anesthetized before the incision, the next layer is then anesthetized, and so on, down to and including the bone itself.

The cumulative result is extremely positive for the patient. The anesthesiologist does not need to administer a narcotic during the case. This results in very steady blood pressure, which leads to less blood loss. And that means a quicker and safer operation without transfusions. Additionally, patients are much more alert after the procedure and require less time in the recovery room.

Because less pain relief is required, patients in the recovery room are quicker to transfer to a regular hospital room where they can start to walk.

Because they have less nausea, they can tolerate a full diet sooner, and report a greater sense of well-being. And of course once they're home, patients have much less need for readmissions for pain, nausea, constipation or failure to manage themselves at home.

Because of my achievements in this area, the hospital where I was working honored me with a quality award — then instructed me to educate my colleagues in the approach! 

It's important to note that the non-narcotic approach is not as effective for patients currently on a narcotic (or those who have been administered a long-term narcotic in the past). This subset of patients has always been difficult to pain manage post-operatively. However the non-narcotic approach still delivers some improvement in these individuals.

Lastly, a word about the drug Tramadol (Ultram), which is an agent I employ routinely. The FDA controls this drug in much the same way it controls narcotics. That being said, it has few side effects, and while dependence has been reported, I have never seen it. I find Tramadol to be an extraordinarily safe and effective medication.

All this said, I think it's important to mention that I am not wedded to any single pain management approach. If a patient believes they will do better with conventional narcotics, I am ready to use them if needed, and will provide the patient with education in narcotic use and recovery. Despite my successes with non-narcotic joint replacement, my primary goal continues to be providing my patients with a centered approach that will result in a safe and successful procedure.