Pain Is Normal. Suffering Does Not Have to Be.
Pain after hip or knee replacement is real. A modern recovery program should never pretend otherwise. Surgery creates a controlled injury, and the body responds with inflammation, swelling, soreness, stiffness, and temporary fatigue. The goal is not to convince patients that they will feel nothing. The goal is to anticipate pain, treat it from several directions, and keep it from interfering unnecessarily with sleep, walking, hydration, nutrition, and rehabilitation.
A successful pain plan does not require a patient to be completely pain-free at every moment. In fact, chasing a pain score of zero can lead to excessive medication, sedation, nausea, constipation, confusion, and fear of normal movement. A better target is functional comfort: pain controlled well enough to stand, walk safely, perform prescribed exercises, rest, and participate in recovery.
This distinction matters. Patients who expect absolutely no discomfort may become alarmed by normal postoperative soreness. Patients who are told that severe pain is simply unavoidable may feel that they have no options other than heavy opioid use. My approach is different. We set realistic expectations, identify the factors that may make pain more difficult to manage, and create a layered plan before surgery begins.
That plan is designed to be strong enough for recovery but flexible enough to change. If pain is mild, the lower steps of the protocol may be sufficient. If pain becomes more intense, additional medications can be added. If a patient cannot take a particular medication because of kidney disease, stomach problems, anticoagulation, allergy, liver disease, drug interactions, or another medical issue, the plan is modified. The objective is intelligent pain control - not undertreatment and not unnecessary overtreatment.
What Does Opioid-Sparing Mean?
“Opioid-sparing” means that every part of the surgical and recovery pathway is organized to reduce the amount of opioid medication a patient may need. It does not mean that pain medication is withheld. It does not mean that every patient must recover without an opioid. It does not mean that a patient has failed if rescue medication becomes necessary.
Traditional vs. Modern Pain Management
The goal is not to withhold pain treatment.
The goal is to use the right tools in the right order.
- Surgery
- Pain escalates
- Opioid becomes primary tool
- More nausea, sedation, constipation
- Mobility may be harder
- Tissue-sparing technique
- Preemptive multimodal plan
- Scheduled non-opioid options
- Early walking, ice and coaching
- Opioid only when appropriate
Instead, opioid-sparing care uses non-opioid strategies first and reserves opioids for situations in which the expected benefit outweighs the potential risks. This is similar to using the right tool for the right job. Opioids can be effective for severe acute pain, but they also have limitations. They can cause nausea, vomiting, constipation, itching, dizziness, drowsiness, urinary retention, impaired balance, confusion, and respiratory depression. They may make it more difficult for some patients to walk safely, participate in therapy, or feel mentally present during the first days of recovery. They also carry risks of prolonged use, dependence, diversion, and accidental exposure to other people in the home.
Reducing opioid use can therefore support more than pain control. It may help patients remain more alert, tolerate food and fluids, avoid constipation, and move with greater confidence. Those advantages are especially relevant in same-day and rapid-recovery joint replacement, where patients are expected to stand, walk, use stairs when needed, and return home within a short period.
There is also an important difference between opioid-naive patients and patients who have been taking opioids before surgery. Prior opioid exposure can increase tolerance and is consistently associated with greater postoperative opioid requirements. Patients who use opioids regularly should not stop them suddenly without guidance. Instead, their pain plan may require coordination with the prescribing clinician, careful expectation setting, and a more individualized strategy. Opioid-sparing remains a valuable goal, but the pathway and expectations may be different.
Why the Operation Itself Matters
Pain management does not begin in the recovery room. It begins with how surgery is performed.
My joint replacement practice emphasizes muscle and tendon-sparing techniques. For hip replacement, I use a direct anterior approach designed to work between muscle planes rather than detaching major muscles or tendons. For knee replacement, I use a subvastus approach when appropriate, preserving the quadriceps tendon and working beneath the vastus medialis rather than cutting through the quadriceps mechanism. I also use contemporary alignment and rapid-recovery principles intended to restore function while limiting unnecessary tissue disruption.
No surgical approach can eliminate inflammation, and the amount of postoperative pain is affected by many factors beyond incision size or approach. However, respecting soft tissue remains a fundamental part of recovery. Every structure that can be preserved does not need to heal from being divided. Careful handling of muscle, tendon, capsule, skin, and surrounding tissue supports the broader goal of reducing the physiologic burden of surgery.
The operation is only one part of the system. A technically excellent replacement followed by an outdated pain plan may still expose a patient to unnecessary side effects. Likewise, a new medication cannot compensate for poor preparation, excessive tissue trauma, unrealistic expectations, or an overly aggressive early rehabilitation program. The best results come from combining thoughtful surgery with thoughtful recovery.
This is why I describe opioid-sparing joint replacement as a pathway rather than a product. It begins with preparation, continues through anesthesia and surgery, and extends into the patient’s home. The medication list is important, but it is not the entire program.
The Multimodal Approach: Several Tools, One Goal
Pain is created and experienced through multiple pathways. Inflammation, local tissue injury, peripheral nerve signaling, muscle guarding, swelling, anxiety, poor sleep, and prior pain exposure can all contribute. Because pain is multifactorial, relying on one medication class is rarely the most effective strategy.
Multimodal pain management uses several complementary methods that work in different ways. The exact combination is tailored to the patient, but the major components may include:
The Multimodal Recovery Pyramid
Pain control begins with the operation and recovery pathway - not with a single prescription.
- Preoperative education and expectation setting, so patients understand what is normal and know how to respond.
- Muscle and tendon-sparing surgical technique, to limit avoidable soft-tissue disruption.
- Anesthesia and regional techniques selected for the operation and the individual patient.
- Acetaminophen, when appropriate, as a scheduled non-opioid analgesic.
- Anti-inflammatory medication, when medically safe, to address inflammation and swelling.
- JOURNAVX® (suzetrigine), when appropriate, as a non-opioid option for moderate to severe acute pain.
- Local measures such as ice, elevation, compression, and swelling control.
- Early, safe movement rather than prolonged bed rest.
- A stepwise rescue plan for breakthrough pain.
- Close communication, so uncontrolled pain or an unexpected change is addressed rather than ignored.
The purpose of combining these tools is not simply to add more medication. It is to reduce dependence on any single medication and allow each component to do a specific job. A scheduled plan can prevent the repeated cycle of waiting until pain becomes severe and then trying to “catch up” with a large rescue dose.
This approach also encourages patients to pay attention to function rather than focusing only on a number. Can you get up safely? Can you walk to the bathroom? Can you eat, drink, and sleep? Is the pain gradually improving? Is swelling expected, or has something changed suddenly? These questions provide more useful information than a pain score alone.
A Closer Look at JOURNAVX®
JOURNAVX® is the brand name for suzetrigine, a prescription non-opioid medication approved by the U.S. Food and Drug Administration in January 2025 for the treatment of moderate to severe acute pain in adults. It is the first approved medication in a new class of non-opioid analgesics that targets a peripheral pain-signaling pathway involving the NaV1.8 sodium channel.
In simple terms, injured tissue activates pain-sensing nerves. Those nerves use electrical signals to carry information toward the spinal cord and brain. Suzetrigine is designed to reduce signaling through NaV1.8 channels in peripheral pain-sensing neurons. It does not work by activating opioid receptors, and it is not an opioid.
That distinction is important. Opioids act within the central nervous system and can reduce pain, but they can also cause sedation, nausea, constipation, impaired breathing, and other opioid-related effects. JOURNAVX® provides another option for acute pain without relying on the opioid receptor pathway.
JOURNAVX® should not be described as a “magic pill,” and it should not be separated from the rest of the recovery program. The pivotal trials that supported FDA approval studied acute pain after abdominoplasty and bunion surgery, not total hip or knee replacement. Experience in arthroplasty is emerging. A 2026 single-surgeon retrospective study evaluated 236 consecutive total hip and knee replacement patients treated with suzetrigine as part of a comprehensive second-generation multimodal protocol. In that series, 89% of patients did not fill a postoperative opioid prescription. Among patients who had not used opioids in the 90 days before surgery, opioid-free recovery was reported in 98.2% of hip replacement patients and 88.7% of knee replacement patients.
Those results are encouraging, but they require context. The study was retrospective, came from one surgeon, and did not isolate the independent effect of suzetrigine from the many other elements of the protocol. The authors specifically cautioned that adding suzetrigine alone to an older pain pathway should not be expected to make every patient opioid-free. Prospective multicenter research is still needed.
That is also how I use the medication in practice: as one important piece of a larger system. The medication may help reduce the need for opioids, but the outcome depends on the operation, anesthesia, the rest of the medication regimen, prior opioid exposure, patient health, expectations, swelling management, activity, and individual pain response.
How JOURNAVX® Works
A simplified patient-education illustration - not a complete pharmacology diagram.
A non-opioid approach that works on a peripheral pain-signaling pathway.
The usual FDA-labeled dosing begins with a 100 mg oral loading dose, followed 12 hours later by 50 mg every 12 hours. The prescribing information should be followed, and the patient’s full medication list must be reviewed. Strong CYP3A inhibitors are contraindicated. Grapefruit-containing food or drink should be avoided because it can increase drug exposure. Dose adjustments or avoidance may be necessary in some patients with liver impairment or when certain interacting medications are used. Common adverse reactions reported in the FDA trials included itching, muscle spasms, increased creatine phosphokinase, and rash. Patients should review the current medication guide and prescribing information and report concerning symptoms.
JOURNAVX® is not appropriate for every patient, and insurance coverage or availability may vary. The decision to use it is made after reviewing medical history, allergies, kidney and liver considerations, current prescriptions, potential drug interactions, and the planned procedure. The medication should only be taken as prescribed.
How My Stepwise Home Protocol Works
My postoperative medication plan is organized so that patients can clearly see which medications are scheduled and which are used only when needed. The specific prescriptions may change based on the procedure and the patient’s medical history, but the overall logic remains consistent.
Scheduled medications create the foundation. In the current protocol, JOURNAVX® is taken on a scheduled basis when prescribed, beginning with the loading dose around the time of surgery and continuing with twice-daily dosing according to the written instructions. Acetaminophen is also scheduled when safe. An anti-inflammatory medication such as ibuprofen may be available as a first-line as-needed option in patients who can safely take it.
If pain is not controlled, the patient moves through a defined rescue sequence rather than taking several medications randomly. A medication such as tramadol may be used for moderate breakthrough pain, followed by a limited stronger opioid such as oxycodone only for severe pain not controlled by the earlier steps. The exact medication and order can vary. The printed discharge instructions - not a website summary - are the authoritative guide for each patient.
This stepwise structure has several advantages. It helps patients avoid taking multiple medications at the same time without understanding their purpose. It encourages use of the lowest effective level of treatment. It makes it easier for the care team to understand what has already been tried when a patient calls. It also provides an important safety framework: patients should not add extra acetaminophen, anti-inflammatory medication, sedating medication, alcohol, or another person’s prescription without guidance.
Medication is paired with non-drug measures. Ice is used regularly while awake during the early phase, with protection between the cold source and skin. Elevation and appropriate compression can help control swelling. Short, frequent walks are generally more useful than a single long session. Exercise should support recovery, not create a cycle of excessive activity followed by severe pain and swelling. Sleep, hydration, protein intake, and treatment of nausea or constipation also influence how patients feel.
The protocol is not designed to prevent patients from calling. Severe or rapidly worsening pain, new neurologic symptoms, excessive swelling, drainage, fever, chest pain, shortness of breath, or calf pain should not simply be treated with additional medication. Patients receive specific postoperative instructions describing when to contact the office and when to seek emergency care.
Who Is Most Likely to Need Rescue Opioids?
Even with a comprehensive protocol, some patients will need an opioid. This is not unexpected and does not mean the pathway failed. The purpose is to reduce unnecessary exposure while maintaining adequate pain control.
Patients who have used opioids in the months before surgery are much more likely to require them afterward. The 2026 arthroplasty study found that preoperative opioid exposure was the strongest predictor of postoperative opioid use. That association reflects tolerance, altered pain processing, the underlying condition for which opioids were prescribed, and other individual factors.
Knee replacement may also require more rescue medication than hip replacement. In the same study, opioid-naive patients had very high opioid-free rates after both procedures, but the rate was lower after knee replacement than hip replacement. This fits the common clinical experience that early knee recovery often involves more swelling, stiffness, and discomfort.
Other factors may include revision surgery, complex reconstruction, chronic pain conditions, anxiety, sleep disturbance, medication intolerance, inability to take anti-inflammatory drugs, medical comorbidities, and individual differences in pain sensitivity. These considerations are discussed before surgery whenever possible.
For patients who already take opioids, planning is especially important. They may need coordination with a pain-management clinician or the provider who normally prescribes the medication. Baseline medication and postoperative rescue medication must be distinguished. Abrupt discontinuation may be unsafe. The goal is a coordinated plan that avoids duplicate prescribing, unrealistic expectations, and preventable withdrawal or uncontrolled pain.
Why Reducing Opioids Can Support Rapid Recovery
Rapid recovery is not simply a shorter hospital stay. It is a coordinated effort to restore normal function while reducing avoidable barriers. Pain control is one of those barriers, but medication side effects can become barriers as well.
Nausea can make it difficult to eat, drink, or take medication. Constipation can become one of the most uncomfortable parts of the first postoperative week. Sedation and dizziness can increase fall risk. Confusion can be particularly concerning in older adults. Itching, urinary retention, and poor sleep can also interfere with recovery. By reducing opioid exposure, many patients may avoid or lessen some of these effects.
Remaining alert is especially important when patients go home the day of surgery. They need to understand instructions, walk with an assistive device, take medications correctly, and recognize warning signs. A family member or support person should still be present, but minimizing unnecessary sedation can make the transition home smoother.
Opioid-sparing care also reduces the number of unused pills that may remain in the home. Unused opioids can be accidentally taken by children, teenagers, visitors, or other family members. They can also be diverted. Any unused controlled medication should be stored securely and disposed of through an approved medication take-back program rather than kept indefinitely.
The broader goal is not to portray opioids as “bad.” These medications can be appropriate and valuable when used carefully. The goal is to stop treating them as the default answer to every level of postoperative pain when effective alternatives and layered strategies are available.
What Recovery May Feel Like
Every patient recovers differently, but several patterns are common. The first few days often involve soreness, swelling, fatigue, bruising, and stiffness. Knee patients may notice that swelling changes throughout the day and increases after activity. Hip patients may experience thigh soreness, tightness, or temporary weakness. Sleep can be disrupted even when daytime pain is controlled.
Pain does not always improve in a perfectly straight line. A patient may feel better one day, increase activity, and then experience more swelling or soreness the next day. This does not automatically mean something is wrong. Recovery should be judged by the overall trend and by function.
A helpful principle is to avoid both extremes: prolonged inactivity and aggressive overexertion. Remaining in bed can worsen stiffness, weakness, constipation, and blood-clot risk. Doing too much too soon can intensify swelling and pain. The recovery plan uses short periods of activity, regular rest, ice, and gradual progression.
Patients should follow their specific physical therapy and exercise instructions. More exercise is not always better. The purpose of early movement is to support circulation, mobility, and confidence - not to force a new joint through severe pain.
The care team should be contacted when symptoms are outside the expected pattern. Examples include pain that is suddenly much worse without explanation, inability to bear weight after a new injury, new foot weakness or numbness, increasing redness or drainage, fever, chest pain, shortness of breath, or significant calf pain. These symptoms require assessment rather than simply stronger medication.
A Recovery Pathway, Not a Single Prescription
Pain management begins before surgery and evolves as healing progresses.
Recovery is individualized. Milestones vary by procedure, health, prior opioid exposure and other factors.
Frequently Asked Questions
Can you guarantee that I will not need an opioid?
No. Many patients can substantially reduce opioid use, and some may recover without taking an opioid, but individual requirements vary. The priority is safe, effective pain control.
Will you refuse to prescribe an opioid if I am in severe pain?
No. Opioids remain available as rescue medication when clinically appropriate. Opioid-sparing care is not the same as withholding treatment.
Is JOURNAVX® an opioid?
No. Suzetrigine is a non-opioid sodium-channel blocker that acts on a peripheral pain-signaling pathway.
Is JOURNAVX® a controlled substance?
JOURNAVX® is not an opioid and is not scheduled as an opioid controlled substance. Patients should still use it only as prescribed and store all medications safely.
Has JOURNAVX® been studied specifically in hip and knee replacement?
A 2026 retrospective single-surgeon study reported encouraging results when suzetrigine was added to a comprehensive multimodal arthroplasty protocol. The pivotal trials supporting FDA approval involved other acute-pain procedures, and further prospective arthroplasty research is needed.
What if my insurance does not cover JOURNAVX®?
Coverage and patient cost vary. The office and pharmacy can help clarify options. The overall opioid-sparing pathway does not depend on one medication alone.
Can I take grapefruit while using JOURNAVX®?
No. Grapefruit-containing food and drink should be avoided because they can affect drug metabolism and increase exposure.
Can I take JOURNAVX® with all of my normal medications?
Not necessarily. Important drug interactions exist, including with strong CYP3A inhibitors. Your complete medication and supplement list must be reviewed.
What if I cannot take anti-inflammatory medication?
The protocol can be modified. Kidney disease, gastrointestinal history, anticoagulation, allergy, cardiovascular considerations, or other factors may limit NSAID use.
Is acetaminophen completely risk-free?
No. Excess acetaminophen can cause serious liver injury. Patients must account for acetaminophen contained in combination products and follow the prescribed maximum daily amount.
Is tramadol an opioid?
Yes. Although sometimes viewed as a weaker medication, tramadol is an opioid and has opioid-related risks as well as additional interaction and seizure considerations.
Why might knee replacement require more medication than hip replacement?
Early knee recovery often involves greater swelling and stiffness. Individual variation is substantial, but published experience suggests opioid-free recovery may be more common after hip replacement than knee replacement.
What if I already take opioids every day?
Tell the surgical team early. Do not stop suddenly without medical guidance. A coordinated perioperative plan may be needed with your regular prescriber or pain-management clinician.
Does less medication mean I should tolerate severe pain?
No. Uncontrolled pain should be addressed. The goal is to use the lowest effective medication level within a structured plan, not to ignore severe symptoms.
Why is ice part of pain management?
Ice can help reduce local discomfort and swelling. It should be used with a protective barrier and according to the postoperative instructions.
Why does early walking help?
Safe movement supports circulation, confidence, function, and return to normal activity. It should be balanced with rest and swelling control.
Will I go home the same day?
Many appropriately selected hip and knee replacement patients can return home the day of surgery, but the decision depends on medical stability, mobility, support, procedure, and other factors.
Is opioid-free recovery the same as pain-free recovery?
No. A patient can experience expected postoperative soreness without using an opioid. The aim is manageable pain and useful function, not a promise of zero discomfort.
How should unused opioids be disposed of?
Use an authorized medication take-back location or follow FDA disposal guidance. Do not share medication or leave it unsecured.
Is this information a substitute for my discharge instructions?
No. Your personalized prescriptions and written postoperative instructions take priority over general website information.
Joint replacement has changed. Pain management has changed. Recovery has changed.
A modern joint replacement pathway should be designed around the whole recovery - not around a routine opioid prescription. By combining tissue-sparing surgery, preparation, multimodal medication, JOURNAVX® when appropriate, swelling control, early movement, and a clear rescue plan, my goal is to help patients recover with effective pain control and less unnecessary opioid exposure.
Not every patient will be opioid-free. Every patient deserves a thoughtful plan.
If hip or knee arthritis is limiting your life, I would be honored to help you understand your options and determine whether rapid-recovery, opioid-sparing joint replacement is appropriate for you.
Final medical disclaimer: This page provides general educational information and does not replace individualized medical advice. Medication selection, dosing, and duration are determined for each patient. Product names are the property of their respective owners. Dr. Nabet has no stated manufacturer affiliation in this content. Confirm any financial relationship or disclosure before publication.
