What is the best practice for postoperative pain medication administration in an inpatient setting for an adult (age 18‑80) undergoing orthopedic surgery without contraindications to non‑opioid agents?

Best Practice for Postoperative Pain Management in Orthopedic Surgery

Implement a multimodal analgesic regimen with scheduled acetaminophen 1g every 6 hours plus NSAIDs as the foundation, add regional anesthesia when feasible, and reserve immediate-release opioids strictly for breakthrough pain only. 1, 2

Core Multimodal Analgesic Foundation

Start with scheduled non-opioid medications as the base:

• Acetaminophen 1g IV or oral every 6 hours (maximum 4g/day) should be initiated preoperatively or intraoperatively and continued throughout the postoperative period 1, 2
• NSAIDs should be added unless contraindicated: ketorolac 15-30mg IV every 6 hours (maximum 5 days per FDA labeling) 3 or ibuprofen 600mg oral every 8 hours 1, 2
• Single intraoperative dose of dexamethasone 8-10mg IV provides both analgesic and antiemetic effects 4, 2

This combination significantly reduces opioid consumption, decreases complications, and improves patient satisfaction compared to opioid-only regimens 5.

Regional Anesthesia Integration

Regional techniques should be strongly considered for orthopedic procedures:

• For hip fractures and lower extremity surgery: peripheral nerve blocks (femoral, fascia iliaca, or lumbar plexus blocks) with long-acting local anesthetics (ropivacaine 0.2-0.5% or bupivacaine) reduce both preoperative and postoperative opioid requirements 1, 2
• Epidural or spinal analgesia is recommended for major orthopedic procedures when skills are available, as it improves pain control, reduces opioid consumption, and decreases delirium risk 1
• Local infiltration of the surgical wound with ropivacaine 0.75% or liposomal bupivacaine at closure provides additional analgesia 2

The 2024 World Journal of Emergency Surgery guidelines provide strong evidence (1A) that regional blocks in elderly hip fracture patients specifically reduce opioid use and improve outcomes 1.

Opioid Management Strategy

When non-opioid multimodal analgesia is insufficient:

• Use immediate-release oral opioids only (liquid oral morphine 10mg/5ml is preferred in the UK guidelines) 1
• Avoid modified-release or transdermal opioid formulations in the acute postoperative setting, as they are associated with harm and increased risk of respiratory depression 1
• Dose should be age-adjusted rather than weight-based, with particular caution in patients over 70 years or those with renal impairment 1
• Limit duration to 5-7 days maximum at discharge, with explicit documentation of dose and duration 1

Monitoring and Assessment Protocol

Pain assessment should guide functional recovery, not just numerical scores:

• Use functional outcomes rather than unidimensional pain scores alone to guide opioid administration 1
• Monitor sedation scores in addition to respiratory rate to detect patients at risk of opioid-induced ventilatory impairment 1
• Assess pain at regular intervals: hourly for the first 6 hours postoperatively, then every 4 hours 4
• Reassess after each intervention for both pain control and adverse effects 4

The American Geriatrics Society emphasizes that adequate pain control itself reduces delirium risk, but this must be balanced against opioid-related cognitive impairment 1.

Adjuvant Medications

Consider gabapentinoids selectively, not routinely:

• Gabapentin 300-600mg or pregabalina 75-150mg may be added for patients at high risk of severe pain, but routine use is not recommended 2, 6
• Monitor for sedation and dizziness, especially in the first 24-48 hours 6
• Taper when no longer indicated rather than continuing indefinitely 1, 2

Reverse Analgesic Ladder for Weaning

When pain improves, follow this specific sequence:

1. Wean opioids first (reduce dose or frequency before stopping)
2. Then discontinue NSAIDs (after 5 days maximum for ketorolac per FDA labeling) 3
3. Finally stop acetaminophen (when pain is minimal) 1

This approach minimizes rebound pain while reducing medication burden systematically 1.

Critical Contraindications and Precautions

Screen for these contraindications before implementing multimodal analgesia:

• NSAIDs should be avoided in patients with cardiovascular disease, significant bleeding risk, active peptic ulcer disease, aspirin-sensitive asthma, or severe renal impairment 2
• Acetaminophen requires dose reduction in patients with pre-existing liver disease and should never exceed 4g/day 4, 2
• Regional blocks require careful timing in patients on anticoagulation to avoid bleeding complications 1
• Benzodiazepines and anticholinergics should be avoided in elderly patients as they increase delirium risk 1

Common Pitfalls to Avoid

These practices increase harm without improving outcomes:

• Do not rely on pain scores alone to guide opioid dosing—this leads to overprescribing and persistent opioid use 1
• Do not use combination analgesics (e.g., oxycodone/acetaminophen)—prescribe separately to allow independent dose adjustments 1
• Do not automatically refill opioid prescriptions—each request requires patient reassessment 1
• Do not prescribe modified-release opioids for acute postoperative pain—they increase respiratory depression risk without improving analgesia 1

The 2021 British Journal of Anaesthesia guidelines and 2021 Anaesthesia international consensus statement both strongly emphasize that long-acting opioids should not be used routinely for acute postoperative pain 1.

Special Considerations for Elderly Patients

Older adults require modified approaches:

• Optimize pain control preferably with non-opioid medications to prevent delirium (strong recommendation from American Geriatrics Society) 1
• Regional anesthesia is particularly beneficial in elderly hip fracture patients for reducing delirium incidence 1
• Opioid selection may differ—in patients over 70 years, alternatives to morphine may be preferred based on renal function 1