Vinod Dasa, MD, used to send knee replacement patients home with prescriptions for dozens, sometimes more than 100, opioid pills.
At the time, it did not feel unusual. Total knee replacement hurt. Patients expected narcotics. Surgeons prescribed them.
“I didn’t know there was anything else,” Dr. Dasa, vice chair of academic affairs and research and the Irv Cahen Chair of Orthopaedic Surgery at Louisiana State University Health New Orleans, told Becker’s.
Then he began cutting back. New pain-control techniques first allowed his team to reduce opioid use substantially. Eventually, he was discharging patients with only five or 10 pills.
That was when he noticed something that changed how he thought about postoperative pain. Patients would tell him they had little or no pain. Then they would tell him they had finished the prescription anyway.
“If you’ve got an orange bottle full of pills, you’re going to take it,” Dr. Dasa said.
So he changed the default. Instead of automatically sending opioid-naive knee replacement patients home with narcotics, his team made them available only if patients called and asked.
About 70% never did. Dr. Dasa has continued refining the protocol. He said preliminary data his team is now analyzing suggest the share of patients recovering without opioids may be approaching 90% to 95% after incorporating another non-opioid pain medication.
For him, the trajectory raises a larger question for orthopedics: How much opioid prescribing reflects what patients actually need — and how much reflects what surgeons have always done?
From ‘just in case’ to ‘only if needed’
Dr. Dasa did not eliminate routine opioid prescribing overnight. His practice gradually reduced the number of pills it prescribed, learning at each step whether patients could manage with less.
The process accelerated when elective surgery resumed after the initial COVID-19 shutdown. His team stopped automatically prescribing narcotics at discharge but kept them available on request.
When the outcomes were compared with patients who had routinely received opioids before the pandemic, roughly 70% of opioid-naive patients recovered without needing a prescription from his team.
That challenged the logic behind “just in case” prescribing. Surgeons may provide enough medication to ensure the patient with unexpectedly severe pain does not call late on a Friday or end up in the emergency department. But that means prescribing for the exception rather than the majority.
“We’re prescribing opioids to 100% of the patients to avoid the phone calls in 30%,” Dr. Dasa said.
He does not expect every surgeon to jump immediately to zero. If a physician routinely prescribes 50 pills, he suggests trying 40. If patients do well, try 30. Keep reducing until the practice finds the point at which less medication begins to compromise care.
“This is a journey,” he said. “This isn’t like just flipping the switch and going to zero.”
Surgeons may not know what happens after the incision heals
The experiment exposed another problem. Even surgeons who believe they are prescribing conservatively may not know how much opioid medication their patients ultimately receive.
When Dr. Dasa’s team reviewed prescription-monitoring data, he said some patients who had not requested opioids from his practice were obtaining them from other clinicians. That challenged the assumption that silence from a patient means everything is going well.
Surgeons are often buffered by physician assistants, nurses, residents and office staff who handle postoperative calls. Once the wound heals, motion returns and complications are ruled out, the surgeon may have little visibility into what happens to a patient’s opioid use afterward.
“I get to walk away,” Dr. Dasa said. “The incision healed. Your motion’s great. No infection. It’s not my problem anymore.”
He believes orthopedics has to reject that boundary. Pain management is part of the surgical outcome, even when another physician eventually writes the prescription.
Outpatient surgery makes expectations part of the treatment
That responsibility becomes more important as joint replacement moves into ASCs. A patient going home hours after surgery needs pain controlled well enough to walk, sleep and recover without returning to an emergency department.
Dr. Dasa said much of that work begins before the operation. When his practice began performing outpatient joint replacements, he learned how easily one person could disrupt a carefully built expectation.
The surgeon, nurse and physician assistant could all tell a patient to expect same-day discharge. If someone else suggested they would probably remain hospitalized for several days, that message could stick.
Pain works similarly. If patients repeatedly hear that joint replacement will be miserable and require strong narcotics, they arrive expecting both.
Dr. Dasa now tells appropriate opioid-naive patients that most people in his practice recover without opioids. Some are relieved. Others worry that their pain will not be treated. For those patients, he explains that opioid-free care does not mean withholding medication.
“The reason I don’t need to give you opioids is because we’ve controlled your pain so well that you don’t need them,” he tells patients. “But if you do need them, we’re going to give them to you.”
The distinction is central to his approach. The goal is not zero opioids at any cost. It is making opioids the backup rather than the default.
The implications extend beyond the recovery room. Dr. Dasa said fear of pain and recovery can keep some patients from pursuing surgery even when they are eligible for it. Better pain management, he argues, can lower that barrier before surgery and help patients return to daily life, and, for those still working, their jobs, sooner afterward.
Standardize the pathway, not the patient
Dr. Dasa does not believe opioid stewardship should become another rigid protocol. His practice starts with a standardized multimodal pain pathway, then adjusts it to the patient.
Some patients remain deeply anxious about going home without a narcotic prescription. If that concern persists after a discussion of alternatives and risks, Dr. Dasa may provide a small prescription as a safety net.
“I meet the patient where they are,” he said.
What changes is the conversation. Instead of receiving opioids simply because every joint replacement patient receives them, the patient makes an informed decision about whether they are necessary.
That philosophy is also shaping a broader effort at the American Academy of Orthopaedic Surgeons. Dr. Dasa is helping lead the academy’s new pain management initiative, which he said is being built around four areas: education, research, advocacy and best practices.
He believes pain deserves greater attention within a specialty that devotes enormous scientific energy to implants, robotics and other surgical technology.
Unlike many orthopedic interventions, opioid prescribing can also reach beyond the patient who underwent surgery. Medication left in a home can affect family members and communities. For Dr. Dasa, that makes pain management a responsibility that does not end when the joint is fixed.
Autonomy requires ownership
He also sees the issue as a test of physician leadership. Prescription-monitoring programs, state limits and federal policies have increasingly pushed medicine toward reducing unnecessary opioid use.
Physicians often object when policymakers dictate how they should practice. Dr. Dasa argues that preserving autonomy requires physicians to address obvious problems before others are forced to do it for them.
“If we don’t take ownership of this, and we don’t show leadership here, it just demonstrates why we shouldn’t lead,” he said.
That may be the broader lesson of his own prescribing evolution. The operation did not suddenly become painless. His team changed the way it prepared patients, controlled pain and decided when medication was actually necessary. For years, the question after orthopedic surgery was how many opioid pills a patient should receive. Dr. Dasa thinks orthopedics should start by asking whether the patient needs the bottle at all.
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