Strategies for Opioid Minimization Following Total Knee Arthroplasty: A Comprehensive Review

The ongoing opioid epidemic has prompted a reexamination of perioperative pain management, especially in total knee arthroplasty (TKA)-a procedure known for its high amount of postoperative pain and historical reliance on opioids. Among strategies for opioid-naïve patients, three broad approaches have emerged: Quantity limitation, dynamic reassessment-based prescribing, and tiered, multimodal pain regimens. While limiting prescription size and scheduling timely follow-ups remain important tools, perhaps an important approach to consider is a tiered, multimodal pain management regimen. This strategy begins with baseline administration of non-opioid agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids, escalating only as needed to tramadol and, if necessary, stronger opioids. Preoperative cryoneurolysis, intraoperative regional nerve blocks, and long-acting local anesthetics further enhance this regimen's ability to minimize opioid exposure. These clinical gains are now reinforced by the Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act, which provides separate Medicare reimbursement for select non-opioid pain treatments beginning in 2025, helping to eliminate financial barriers to adoption of these measures. In addition, real-world data-including results from the Innovations in Genicular Outcomes Research (iGOR) registry-have demonstrated the effectiveness of these techniques in reducing opioid use and improving functional and quality-of-life outcomes following TKA. Together, this convergence of clinical strategy, supportive policy, and data infrastructure provides a scalable and sustainable framework for advancing opioid stewardship in orthopaedic surgery without compromising patient comfort or recovery.