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Managing Pain and Opioids After Surgery

How pain is managed after upper-limb surgery — multimodal pain relief, the role and risks of opioids, nerve blocks, and using the least medication needed.

Overview

Optimizing pain management after joint arthroplasty requires multimodal, opioid-sparing regimens that incorporate both pharmacologic and nonpharmacologic agents [3]. For total knee arthroplasty, a modern opioid-free multimodal analgesia regimen is important for optimizing pain management [2]. Intraoperative dexamethasone reduces early pain and opioid needs after primary cementless total hip arthroplasty using the direct anterior approach [1]. It also offers meaningful preliminary insight into opioid-sparing potential in the context of neuraxial total hip arthroplasty [6]. However, current trials have limitations including fixed dosing, lack of power for secondary outcomes, and insufficient safety monitoring [1]. Future studies should refine dosing, ensure adequate power, and monitor safety endpoints over a longer recovery period [1]. Weight-based dosing and long-term effects require further investigation [6].

Preoperative risk stratification is critical for postoperative opioid prescribing. Patients with preoperative fibromyalgia undergoing hip arthroscopy have significantly higher odds of receiving opioid prescriptions within 90 days [4] and 1 year [4] postoperatively compared to matched controls, though they have similar 2-year reoperation rates [4]. Preoperative nonopioid analgesia reduces postoperative opioid consumption [5] and VAS pain scores [5] after arthroscopic surgery, although these reductions may not represent clinically meaningful improvements [5]. Approximately 39% of preoperative opioid users continued use for 10 to 12 months after elective joint surgery, compared with 9% of nonchronic users [8].

Specific adjuncts and regional techniques offer targeted benefits. The use of 75 mg pregabalin is advocated as part of a contemporary multimodal analgesic regimen for postoperative pain management after total knee arthroplasty [9]. Tranexamic acid in local infiltration analgesia cocktail reduces pain after total knee arthroplasty, but this reduction does not meet the minimal clinically important difference (MCID) [11]. Single epidural analgesia with opioid-free IV-PCA significantly reduces total fentanyl consumption compared with conventional opioid-based IV-PCA in lumbar spine surgery, with no clinically important differences in pain control [10]. Demographic and regional factors in zone II flexor tendon repairs suggest different needs for different cohorts and room for more consistent pain management strategies [7].

How It Works

Pharmacologic and Device-Based Interventions: Intraoperative dexamethasone reduces early pain and opioid needs after primary cementless total hip arthroplasty using the direct anterior approach with neuraxial anesthesia [1]. A modern opioid-free multimodal analgesia regimen optimizes pain management after total knee arthroplasty [2]. Multimodal, opioid-sparing regimens that incorporate both pharmacologic and nonpharmacologic agents offer the most balanced approach to pain management after total joint arthroplasty [3]. The use of 75 mg pregabalin is advocated as part of a contemporary multimodal analgesic regimen for postoperative pain management after total knee arthroplasty [9]. The use of a nanotechnology-based device (NBD) is significantly associated with an immediate reduction in postoperative opioid use after total knee arthroplasty [14].

Regional and Local Anesthesia Strategies: Preoperative nonopioid analgesia reduces postoperative opioid consumption after arthroscopic surgery [5]. Preoperative nonopioid analgesia reduces VAS pain scores after arthroscopic surgery [5]. The observed reductions in postoperative opioid consumption and VAS pain scores from preoperative nonopioid analgesia may not represent clinically meaningful improvements [5]. An epidural opioid-free IV-PCA protocol significantly reduces total fentanyl consumption compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery [10]. There are no clinically important differences in pain control between epidural opioid-free IV-PCA and conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery [10]. The reduction in pain from tranexamic acid in local infiltration analgesia cocktail for total knee arthroplasty did not meet the minimal clinically important difference (MCID) [11]. The use of tranexamic acid reduces opioid consumption after arthroscopic rotator cuff repair [12].

Patient and Surgical Factors Influencing Opioid Consumption: Patients with preoperative fibromyalgia undergoing hip arthroscopy have significantly higher odds of receiving opioid prescriptions within 90 days postoperatively compared to matched controls [4]. Patients with preoperative fibromyalgia undergoing hip arthroscopy have significantly higher odds of receiving opioid prescriptions within 1 year postoperatively compared to matched controls [4]. Advancing age modulates postoperative opioid consumption after arthroscopic rotator cuff repair [12]. Preoperative opioid use increases opioid consumption in the first 3 days after arthroscopic rotator cuff repair [12]. The number of anchors used increases opioid consumption in the first 3 days after arthroscopic rotator cuff repair [12]. Patients who had resurfaced patellae had greater opioid consumption in the first 30 days postoperatively compared to those who had unresurfaced patellae after total knee arthroplasty [19].

Postoperative Outcomes and Long-Term Use: The use of a nanotechnology-based device (NBD) is significantly associated with a reduction in postoperative PONV after total knee arthroplasty [14]. The use of a nanotechnology-based device (NBD) is significantly associated with reduced use of rescue antiemetics after total knee arthroplasty [14]. The use of a nanotechnology-based device (NBD) is significantly associated with facilitated earlier discharge from the hospital after total knee arthroplasty [14]. Poor postoperative pain tolerance and increased opioid requirements may serve as early predictive markers for an increased risk of postoperative knee stiffness and subsequent manipulation under anesthesia (MUA) after total knee arthroplasty [17]. Approximately 39% of preoperative opioid users continued use of opioids for 10 to 12 months after elective joint surgery [8]. Approximately 9% of nonchronic opioid users continued use of opioids for 10 to 12 months after elective joint surgery [8].

What the Evidence Shows

Pharmacologic Interventions and Multimodal Regimens

Intraoperative Dexamethasone: Administration reduces early pain and opioid needs after primary cementless total hip arthroplasty (THA) using the direct anterior approach with neuraxial anesthesia [1]. However, current trials exhibit limitations including fixed dosing, lack of power for secondary outcomes, and insufficient safety monitoring [1]. Future studies must refine dosing, ensure adequate power, and monitor safety endpoints over a longer recovery period [1]. Specifically, weight-based dosing and long-term comprehensive safety metrics require further investigation [6].

Preoperative Nonopioid Analgesia: This strategy reduces postoperative opioid consumption and Visual Analog Scale (VAS) pain scores after arthroscopic surgery [5]. These observed reductions may not represent clinically meaningful improvements [5]. A single preoperative dose of methadone (10 mg) is effective and safe in primary total knee arthroplasty (TKA) for reducing postoperative opioid usage [15]. It maintains a similar or better level of pain control compared to a standard pain control regimen [15].

Adjuvant Agents: Low-dose pregabalin (75 mg) is advocated as part of a contemporary multimodal analgesic regimen for postoperative pain management after TKA [9]. Perioperative administration of mirogabalin did not reduce opioid consumption or postoperative pain after THA [21]. It was associated with an increased incidence of central nervous system-related adverse events after THA [21].

Tranexamic Acid: In local infiltration analgesia cocktails for TKA, tranexamic acid reduces pain, but the reduction did not meet the minimal clinically important difference (MCID) [11]. It reduces opioid consumption after arthroscopic rotator cuff repair (ARCR) [12].

Regional and Epidural Analgesia

Epidural Analgesia: Single epidural analgesia with opioid-free IV-PCA significantly reduces total fentanyl consumption compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery [10]. There are no clinically important differences in pain control between these two methods [10].

Rehabilitation and Device-Based Strategies

Rehabilitation Protocols: The quiet knee rehabilitation protocol after primary TKA is associated with lower inpatient opioid exposure, lower 90-day post-discharge opioid exposure, and shorter hospital length of stay compared with conventional hands-on, aggressive post-TKA rehabilitation [22]. It has no added risks to pain, function, or major complications compared with conventional rehabilitation [22].

Nanotechnology-Based Devices: A nanotechnology-based device (NBD) is significantly associated with an immediate reduction in postoperative opioid use following TKA [14]. It is significantly associated with a reduction in postoperative PONV and reduced use of rescue antiemetics following TKA [14]. The device facilitates earlier discharge from the hospital following TKA [14].

Multidisciplinary Approaches: A multidisciplinary approach is effective for reducing inpatient opioid consumption in operatively treated upper extremity fracture patients [16]. The greatest reduction in opioid consumption from this approach occurs on postoperative days 1 and 2 [16].

Patient-Specific Risk Factors and Outcomes

Preoperative Opioid Use: Approximately 39% of preoperative opioid users continued use of opioids for 10 to 12 months after elective joint surgery [8]. Approximately 9% of nonchronic opioid users continued use of opioids for 10 to 12 months after elective joint surgery [8]. Patients utilizing opioids before total joint arthroplasty have greater social determinants of health deficits than opioid-naïve patients [13].

Fibromyalgia: Patients with preoperative fibromyalgia undergoing hip arthroscopy have significantly higher odds of receiving opioid prescriptions within 90 days postoperatively compared to matched controls [4]. They also have significantly higher odds of receiving opioid prescriptions within 1 year postoperatively compared to matched controls [4]. However, they have similar 2-year reoperation rates compared to matched controls [4].

Arthroscopic Rotator Cuff Repair (ARCR) Factors: Advancing age modulates postoperative opioid consumption after ARCR [12]. Preoperative opioid use increases opioid consumption in the first 3 days after ARCR [12]. The number of anchors used increases opioid consumption in the first 3 days after ARCR [12]. Levels of preoperative anxiety in opioid-naive patients undergoing primary ARCR had no significant effect on total postoperative opioid usage [20]. Preoperative anxiety had no significant effect on the number of days opioid medication was taken [20]. Preoperative anxiety had no significant effect on the adjusted daily opioid usage [20].

Flexor Tendon Repairs: Demographic factors associated with morphine milligram equivalents (MMEs) prescribed after zone II flexor tendon repairs may suggest different needs for different cohorts [7]. Regional factors in zone II flexor tendon repairs suggest room for more consistent pain management strategies [7].

Practical Considerations

Intraoperative Pharmacologic Adjuncts: Intraoperative dexamethasone reduces early pain and opioid needs after primary cementless total hip arthroplasty using the direct anterior approach with neuraxial anesthesia [1]. However, current trials exhibit limitations including fixed dosing, lack of power for secondary outcomes, and insufficient safety monitoring [1]. Future investigations must refine dosing, ensure adequate power, and monitor safety endpoints over a longer recovery period [1]. Specifically, weight-based dosing, long-term effects, and comprehensive safety metrics for dexamethasone require further study [6].

Multimodal and Opioid-Sparing Regimens: A modern opioid-free multimodal analgesia regimen optimizes pain management after total knee arthroplasty [2]. Multimodal, opioid-sparing regimens incorporating pharmacologic and nonpharmacologic agents offer a balanced approach to pain management after total joint arthroplasty [3]. The use of 75 mg pregabalin is advocated as part of a contemporary multimodal analgesic regimen for postoperative pain management after total knee arthroplasty [9]. A single preoperative dose of methadone (10 mg) reduces postoperative opioid usage while maintaining a similar or better level of pain control compared to a standard pain control regimen in primary total knee arthroplasty [15].

Preoperative Optimization and Risk Stratification: Preoperative nonopioid analgesia reduces postoperative opioid consumption after arthroscopic surgery [5]. Preoperative nonopioid analgesia reduces VAS pain scores after arthroscopic surgery [5], although observed reductions in postoperative opioid consumption and VAS pain scores may not represent clinically meaningful improvements [5]. Patients with preoperative fibromyalgia undergoing hip arthroscopy have significantly higher odds of receiving opioid prescriptions within 90 days postoperatively compared to matched controls [4]. Patients with preoperative fibromyalgia undergoing hip arthroscopy have significantly higher odds of receiving opioid prescriptions within 1 year postoperatively compared to matched controls [4]. Patients with preoperative fibromyalgia undergoing hip arthroscopy have similar 2-year reoperation rates compared to matched controls [4].

Preoperative Opioid Use and Social Determinants: Approximately 39% of preoperative opioid users continued use of opioids for 10 to 12 months after elective joint surgery [8]. Approximately 9% of nonchronic opioid users continued use of opioids for 10 to 12 months after elective joint surgery [8]. Patients using opioids preoperatively are more likely to have a social determinant of health deficit compared to opioid-naïve patients [13].

Procedure-Specific Modulators and Regional Strategies: Advancing age modulates postoperative opioid consumption after arthroscopic rotator cuff repair [12]. Preoperative opioid use increases opioid consumption in the first 3 days after arthroscopic rotator cuff repair [12]. The number of anchors used increases opioid consumption in the first 3 days after arthroscopic rotator cuff repair [12]. An epidural opioid-free IV-PCA protocol significantly reduces total fentanyl consumption compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery [10]. There are no clinically important differences in pain control between epidural opioid-free IV-PCA and conventional opioid-based IV-PCA in lumbar spine surgery [10].

Multidisciplinary and Demographic Factors: A multidisciplinary approach is effective for reducing inpatient opioid consumption in operatively treated upper extremity fracture patients [16]. The greatest reduction in inpatient opioid consumption from a multidisciplinary approach occurs on postoperative days 1 and 2 for operatively treated upper extremity fracture patients [16]. Demographic factors associated with morphine milligram equivalents (MMEs) prescribed after zone II flexor tendon repairs may suggest different needs for different cohorts [7]. Regional factors suggest room for more consistent pain management strategies following zone II flexor tendon repairs [7].

Key Evidence

  • [L5] The authors commend the original trial's evidence that intraoperative dexamethasone reduces early pain and opioid needs but highlight limitations including fixed dosing, lack of power for secondary outcomes, and insufficient safety monitoring, advocating for future work to refine dosing, ensure adequate power, and monitor safety endpoints over a longer recovery period. (10.1016/j.arth.2025.07.051)
  • [L3] This study highlights the importance of a modern opioid-free multimodal analgesia regimen in optimizing pain management after TKA. (10.1016/j.arth.2025.09.011)
  • [L4] Multimodal, opioid-sparing regimens that incorporate both pharmacologic and nonpharmacologic agents offer the most balanced approach to pain management after TJA. (10.1016/j.arth.2026.03.068)
  • [L3] However, patients with fibromyalgia had significantly higher odds of receiving opioid prescriptions within both 90 days and 1 year postoperatively. (10.1002/arj.70003)
  • [L1] Despite statistically significant findings, observed reductions in postoperative opioid consumption and VAS pain scores may not represent clinically meaningful improvements. (10.1177/03635465251396164)
  • [L5] The authors acknowledge the need for future studies to investigate weight-based dosing, long-term effects, and comprehensive safety metrics, while maintaining that their findings offer meaningful preliminary insight into dexamethasone's opioid-sparing potential in the context of neuraxial THA. (10.1016/j.arth.2025.07.055)
  • [L2] Demographic factors associated with MMEs prescribed may suggest different needs for different cohorts, but regional factors suggest room for more consistent pain management strategies. (10.1016/j.jhsg.2026.100971)
  • [L3] Approximately 39% of preoperative opioid users and 9% of nonchronic opioid users continued use of opioids for 10 to 12 months after surgery. (10.1016/j.arth.2025.06.053)
  • [L1] Therefore, the authors advocate for the use of 75 mg pregabalin as part of a contemporary multimodal analgesic regimen for postoperative pain management after TKA. (10.1016/j.arth.2025.06.068)
  • [L1] Despite no clinically important differences in pain control, the epidural opioid-free IV-PCA protocol significantly reduced total fentanyl consumption compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery. (10.1097/corr.0000000000003891)
  • [L1] However, the reduction in pain did not meet the MCID, indicating limited clinical relevance in terms of analgesia. (10.1186/s42836-026-00385-8)
  • [L1] Advancing age modulated postoperative opioid consumption, whereas preoperative opioid use and number of anchors used increased opioid consumption in the first 3 days after ARCR. (10.1016/j.jse.2025.07.023)
  • [L3] Patients using opioids preoperatively are more likely to have a social determinant of health deficit compared to opioid-naïve patients, which may indicate differences in pathways of care and highlights the influence of social determinants of health on patient outcomes following total joint arthroplasty. (10.1016/j.arth.2025.08.033)
  • [L1] This randomized placebo-controlled study demonstrates that the use of NBD is significantly associated with an immediate reduction in postoperative opioid use, PONV, use of rescue antiemetics, and hospital LOS. (10.1016/j.arth.2026.04.083)
  • [L1] This study demonstrated the effectiveness and safety of a single preoperative dose of methadone (10 mg) in primary TKA in reducing postoperative opioid usage while maintaining a similar or better level of pain control when compared to a standard pain control regimen. (10.1016/j.arth.2025.06.058)
  • [L3] A multidisciplinary approach is effective for reducing inpatient opioid consumption in operatively treated upper extremity fracture patients, with the greatest reduction seen on POD 1 and 2. (10.1016/j.jseint.2026.101685)
  • [L3] Poor postoperative pain tolerance and increased opioid requirements may serve as early predictive markers that portend an increased risk of postoperative knee stiffness and subsequent MUA. (10.1016/j.arth.2026.03.042)
  • [L3] Patients who had resurfaced patellae had a greater opioid consumption in the first 30 days postoperatively compared to those who had unresurfaced patellae. (10.1016/j.arth.2026.01.001)
  • [L2] Levels of preoperative anxiety in opioid-naive patients undergoing primary ARCR had no significant effect on total postoperative opioid usage, the number of days opioid medication was taken, or the adjusted daily opioid usage. (10.1177/23259671261427788)
  • [L2] Perioperative mirogabalin did not reduce opioid consumption or postoperative pain after THA and was associated with an increased incidence of CNS-related adverse events. (10.1016/j.arth.2026.03.095)
  • [L3] Compared with conventional hands-on, aggressive post-TKA rehabilitation, the quiet knee protocol was associated with lower inpatient and 90-day post-discharge opioid exposure and shorter LOS, without detriment to pain, function, or major complications. (10.1016/j.arth.2026.03.083)

References

[1] Comment on “A Randomized, Double-Blind, Placebo-Controlled Trial on the Efficacy of Dexamethasone Combined With Neuraxial Anesthesia in Reducing Pain and Opioid Consumption After Primary Cementless Total Hip Arthroplasty Using the Direct Anterior Approach”. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.051

[2] In-Hospital Exposure and Opioids Prescribed after Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.09.011

[3] Emerging Nonopioid Analgesic Strategies in Total Joint Arthroplasty: Mechanisms, Evidence, and Practical Implementation. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.068

[4] Patients With Preoperative Fibromyalgia Undergoing Hip Arthroscopy Demonstrated Increased Odds of Postoperative Opioid Prescriptions Within 90 Days and 1 Year but Similar 2‐Year Reoperation Rates Compared to Matched Controls. Arthroscopy. 2026. DOI: 10.1002/arj.70003

[5] Preoperative Nonopioid Analgesia Reduces Postoperative Opioid Consumption After Arthroscopic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251396164

[6] Reply to Letter Regarding “A Randomized, Double-Blind, Placebo-Controlled Trial on the Efficacy of Dexamethasone Combined With Neuraxial Anesthesia in Reducing Pain and Opioid Consumption After Primary Cementless Total Hip Arthroplasty Using the Direct Anterior Approach”. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.055

[7] Opioid Prescription Patterns Following Zone II Flexor Tendon Repairs: A National Database Study. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100971

[8] Opioid Consumption Patterns Before and After Elective Joint Surgery. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.053

[9] Analgesic Efficacy and Side Effects of Low-Dose Pregabalin As a Modern Multimodal Agent for Postoperative Pain Control After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.068

[10] Single Epidural Analgesia With Opioid-free IV-PCA Reduces Opioid Consumption in Lumbar Spine Surgery: A Randomized, Multicenter Trial. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003891

[11] Tranexamic acid in local infiltration analgesia cocktail for pain and swelling after total knee arthroplasty: a randomized controlled trial. Arthroplasty. 2026. DOI: 10.1186/s42836-026-00385-8

[12] Use of tranexamic acid reduces opioid consumption after arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.07.023

[13] Patients Utilizing Opioids Before Total Joint Arthroplasty Have Greater Social Determinants of Health Deficits than Opioid-Naïve Patients. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.033

[14] Nanotechnology-Based Device Reduces Pain and Immediate Opioid Requirements and Facilitates Earlier Discharge From the Hospital Following Total Knee Arthroplasty: A Randomized Placebo-Controlled Trial. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.083

[15] Optimizing Postoperative Pain Management in Total Knee Arthroplasty With Preoperative Methadone: A Prospective, Randomized Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.058

[16] The role of a multidisciplinary approach to opioid reduction for patients with operatively treated upper extremity fractures. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101685

[17] Increased Opioid Consumption Following Total Knee Arthroplasty Is Associated With an Increased Risk of Manipulation Under Anesthesia. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.042

[19] Opioid Consumption Trends in Resurfaced versus Unresurfaced Patellae in Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.01.001

[20] Preoperative Anxiety Levels and Postoperative Opioid Use in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261427788

[21] Perioperative Administration of Mirogabalin for Postoperative Pain Management Following Total Hip Arthroplasty: A Randomized Controlled Trial. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.095

[22] Quiet Knee Rehabilitation Protocol After Primary Total Knee Arthroplasty Is Associated with Lower Opioid Exposure and No Added Risks: A Retrospective Cohort Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.083

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a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.