**2. Incidence of pain**

Postoperative pain is a common phenomenon after an orthopedic surgery and can be a limiting factor for the patient's recovery. The incidence of postoperative pain can vary depending on the type and technique of the surgery.

It is well known that the joint replacement surgery and spine surgery are the most painful surgeries, postoperative talking. In a multicenter study, by Arefaine [1] et al., in 2020, they found that moderate to severe postoperative pain was present in 70.5% of patients who underwent an orthopedic emergency surgery. They also found that orthopedics patients who had preoperative anxiety were 6.42 times more likely to develop moderate to severe postoperative pain compared with those patients who were not anxious, among other factors like history of preoperative anxiety, history of preoperative pain, preoperative patient expectation about postoperative pain, intraoperative use of tourniquet, type of anesthesia and duration of anesthesia were significant.

To handle the postoperative pain in an orthopedic surgery, several strategies have been used. One of the most common strategies is opioid use. However, some of the adverse effects they can cause nausea, vomit, sedation, and constipation. Also, opioid use can be addictive and increase it overdose use. Another strategy for an adequate postoperative pain management is the use of peripheral nerve blocks; studies demonstrated higher reported patient satisfaction of postoperative pain control in patients who received combined [2].

Peripheral nerve blocks (PNB) have remarkable benefits for immediate postoperative pain control after primary total hip arthroplasty (THA). The analgesic effect of PNB with IV PCA was better than conventional IV PCA alone [3].

Multimodal Analgesia (MMA), also referred to as "balanced analgesia," uses multiple analgesic medications, physical modalities, and cognitive strategies to affect peripheral and central nerve loci for the treatment of pain [4].

In regard of the technique, some studies found no significant difference in pain control, but they report significantly more effective in early mobilization with intraarticular infiltration [5].

#### **2.1 Opioid overdose and addiction in the intrahospital setting**

Opioid overdose and addiction are a common problem in the intrahospital setting, especially in patients who receive them for postoperative pain prolonged periods. Opioids are a class of analgesic that is highly effective and can be highly addictive and dangerous if wrongly used. According to a report from the CDC of the US, the rate of deaths for overdose use of opioids in the country went as high as 38% in 2019 and 2020, suggesting that the crisis is far from gone [6].

In the intrahospital setting, opioid overdose can occur as a result of an accidental or intentional overdose, or from an interaction with other medication. According to a study published in *JAMA Surgery Magazine*, 8.8% of patients that received opioids after a surgery developed addiction after 6 months [7]. In order to prevent overdose and addiction in the intrahospital setting, various strategies have been implemented. One of the most effective strategies is the protocol implementation for multimodal pain management, which imply the use of multiple analgesia modalities, like the peripheral nerve block and regional anesthesia [5]. They also implemented the use of short-action opioids and the reduction of prolonged-action opioids.

They have also implemented education and capacitation of medical and nurse professionals about the appropriate use of opioids and the early detection in its addiction, as well as the supervision of patients receiving opioids to detect early addiction or overdose signs. In conclusion, multimodal pain management protocol implementation, education and capacitation of medical and nurse professionals, and supervision are effective strategies for preventing these kinds of problems.
