Purpose Enhanced recovery protocols for total hip arthroplasty (THA), using opioid-sparing techniques have become widely used. Reports of novel additions to multimodal pain control regimens have been published, however, a paucity of literature exists on the use of intravenous dexmedetomidine. In this study, we analyzed our experience with intravenous dexmedetomidine and hypothesized that it would reduce postoperative opioid use. Secondary outcomes were also examined, including post-operative hypotension, hemoglobin, length of stay, and discharge disposition. Methods All patients who underwent primary THA at a single tertiary-level center between January 1, 2016, and September 1, 2019, underwent investigation. Diagnosis, surgical approach, anesthetic type, body mass index (BMI), and American Society of Anesthesiologists (ASA) score were recorded. Postoperative clinical measures were analyzed, adjusting for patient and surgical characteristics. Results Of the 599 patients included in the study, 218 patients received intravenous (IV) dexmedetomidine, at a mean dose of 44.9 mg during their operative event. Using a multivariate model, patients in the IV dexmedetomidine group were estimated to have received 24% elevated morphine milligram equivalent at postoperative day zero compared to those in the control group (p = 0.05). In addition, patients in the IV dexmedetomidine group who underwent spinal anesthesia had increased odds of hypotension 3.47 times that of the control [odds ratio (OR) 1.43-8.43, p=0.006]. Conclusions Surprisingly, we found no opioid-sparing effects with the use of IV dexmedetomidine. IV dexmedetomidine may be used cautiously as an anesthesia adjunct with spinal anesthesia in the setting of primary THA, as the experience at our institution illustrated increased odds of postoperative hypotension. Level of evidence This retrospective case-control study has a level of evidence III.