Planning for Proper Pain Management

Discuss with your patients what they should expect in terms of pain following their procedures and your facility's pain management protocols a week or two before surgery. They should know in advance, for example, that they'll experience a spike in pain on day 2 or 3 post-op when nerve blocks wear off. Explain the effectiveness of non-opioid alternative therapies and how they'll play a key role in minimizing the amount of opioids they will need to take. For example, acetaminophen and NSAIDs such as ibuprofen, naproxen and celecoxib are effective adjunct therapies that limit opioid consumption.

The opioids surgeons prescribe should be for the shortest duration possible — a 7-day supply is usually sufficient to manage pain after most surgeries — low-dose and short-acting. Also establish a default number of pills that are prescribed following specific procedures (see "Standardized Scripts for Every Surgery" here for more about recommended pill counts).

During pre-op consultations or assessments, share brochures and other educational materials with patients about safe opioid use. Remind them that your staff and surgeons are available at any point before and after their procedures to answer questions they have about your opioid-sparing protocols. Encourage patients to keep a pain diary. Jotting down notes about how they feel can help them better understand what treatments are working, and which aren't. Referencing those firsthand accounts of a patient's recovery during post-op clinic visits will help surgeons refine their pain management regimens.

Before and after surgery, warn patients about the dangers of excessive opioid use and the risks involved in combining opioids with other substances without physician oversight. Many of the deaths characterized as opioid overdoses in the media are in fact the result of mixing opioids with benzodiazepines or alcohol, which can lead to fatal respiratory arrest.

It's not always the patients who receive prescribed opioids who end up misusing them.

Counsel patients and their caregivers on how to properly store and dispose of controlled substances. It's not always the patients who receive prescribed opioids who end up misusing them; friends and family members with access to unsecured or leftover medications are also at risk. Similarly, warn patients about taking nonprescribed opioids they "borrowed" from a friend or relative.

Check if patients have a history of opioid abuse or chronic use to determine if greater care is needed to monitor their current usage or if the medications should be avoided altogether. Review patients' medical records for information about prior use of prescribed opioids and check state-run databases to see if patients have a history with controlled substances that might not be noted in their personal records. Pre-op screening should also include conversations with patients about elements of their health histories — and the health histories of their family members — that could make them prone to opioid misuse, including substance use disorder, excessive alcohol and tobacco consumption, and history of depression or anxiety.

Post-op phone calls should include a discussion of any ongoing issues patients are having with the healing process, assessment of the pain level they're experiencing and checking to ensure they've stopped using opioids if their pain has resolved. Remember to use compassion and empathy when addressing patients regarding their pain management issues. This encourages an ongoing dialogue. If a patient, for example, requests more opioids during the post-op phone call, or if you encounter the very rare patient who is truly drug-seeking, you can refer them to a pain specialist or their surgeon for appropriate follow-up care.

As medical professionals, we have a clear responsibility to treat patients' pain effectively and safely. We also have a clear responsibility to help slow the tide of drug addiction and overdose deaths. Adopting best prescribing practices and having a plan in place to implement them will ensure you continue to provide patients with the quality care they deserve. OSM