Opioid Prescribing for Safe, Effective Postsurgical Pain Management

Smarter prescribing of opioids following surgery can help prevent dependence and overuse of these drugs, panelists said at the 2021 virtual American College of Surgeons Clinical Congress.

“As surgeons, it’s important that we understand what our role is in the opioid epidemic,” said Bridget Fahy, MD, FACS, a professor of surgery and the chief of surgical oncology at the University of New Mexico Health Sciences Center, in Albuquerque.

Opioids are prescribed in 80% of surgical procedures, Dr. Fahy said. Approximately 6% of opioid-naive patients are prescribed opioids after minor procedures, and will continue using them three to six months later. Of long-term opioid users, 27% received their original prescription after surgery and have a substantially increased risk for opioid dependence and use disorder.

Surgeons should use different opioid prescribing strategies related to patient characteristics, said Melissa Red Hoffman, MD, ND, FACS, an acute care surgeon at Mission Hospital and an inpatient hospice physician at the John C. Keever Solace Center, both in Asheville, N.C. Care providers should be mindful about opioid prescribing in patients who are naive to treatment and undergoing uncomplicated elective operations, she said.

“The risk of transitioning from short- to long-term use begins to increase after the fifth day of exposure,” Dr. Hoffman said. “Patients who receive a five-day supply of opioids have a 7% chance of continued opioid use at one year.”

Preoperative management for these patients should include setting expectations about postoperative pain; discussing usual opioid consumption; and providing instructions on use of nonopioid pain medication and safe opioid use and disposal, she said. Perioperative care can incorporate acetaminophen (1 g preoperatively), infiltration of port sites with lidocaine, 30 mg of IV ketorolac given at the end of the procedure, and just telling post-acute care nurses to give opioids sparingly.

At discharge, Dr. Hoffman said, set expectations regarding postoperative pain and ensure patients have options to contact the team with questions. Instruct patients to take acetaminophen and ibuprofen on a scheduled basis for at least 72 hours. If prescribing opioids, use recommendations established by the Michigan OPEN (Opioid Prescribing Engagement Network). Patients should take opioids only for breakthrough pain during the first 24 to 48 hours after surgery.

For patients on long-term opioid therapy, verify the home opioid dose using your state’s prescription drug monitoring program (PDMP), Dr. Hoffman said. It is appropriate to continue established opioid medications throughout the hospital stay. However, that dose likely will not be enough to control any additional acute surgical pain. Multimodal analgesia should be used. If a patient cannot tolerate oral medications, consider converting to IV dosing of the home opioid or its equivalent.

At discharge, if opioids are needed for acute pain, inquire whether the patient has a pain contract, she advised. If so, contact the patient’s pain physician to discuss the need for additional opioids. For patients taking more than 50 morphine milligram equivalents (MMEs) per day, consider coprescribing naloxone.

When using the PDMP database, Dr. Hoffman said, it is important to know if patients are receiving either methadone or buprenorphine from an opioid treatment program; that prescription likely will not show up in the database. In addition, consider prescribing or coprescribing naloxone for patients who have an opioid use disorder, those who take more than 50 MMEs per day, and those who take an opioid and a benzodiazepine concomitantly.

Pain management for patients with opioid use disorder who are on medication-assisted treatment (MAT) has its own considerations, Dr. Hoffman said. There are four main misconceptions regarding the treatment of acute pain in patients on MAT:

• The maintenance dose of methadone and buprenorphine will provide adequate analgesia for acute pain. Actually, patients are likely to require higher doses of opioids.
• Providing opioids to these patients will result in relapse. In fact, stopping MAT and not adequately treating acute pain is more likely to result in relapse than treating acute pain with additional opioids.
• Buprenorphine causes respiratory depression and therefore needs to be stopped before starting an opioid for acute pain. In fact, stopping buprenorphine will cause patients to have a significant opioid debt that will necessitate even higher doses of opioids.
• Patients with opioid use disorder who endorse pain are showing drug-seeking behaviors. In truth, patients with known opioid use disorder may have developed opioid tolerance, as well as opioid-induced hyperalgesia.

For patients on methadone, verify the maintenance dose with the opioid treatment program, Dr. Hoffman said. Methadone should be continued throughout hospitalization. Remember that the maintenance dose, even if it’s high, will not be enough to provide relief of acute pain. Use multimodal analgesia, and because of the alpha-elimination of methadone that is associated with analgesia, consider splitting the maintenance dose into twice-daily dosing to assist with pain control.

For patients who cannot take drugs by mouth, conversion to IV dosing should be done with the help of the pharmacy or a palliative care provider, she said. If the regular dose of methadone is interrupted for five or more days, reintroduction should only be done by a knowledgeable provider. Consider peripheral and regional anesthesia as well as opioids. Note that methadone will lengthen the QTc interval, so try to avoid other QTc-prolonging drugs.

At discharge, contact the opioid treatment program and inform them of the patient’s discharge plan, including the timing of the last dose of methadone, and whether any other opioids have been prescribed, Dr. Hoffman said.

For patients on buprenorphine, verify the dose from the PDMP or opioid treatment program. During the perioperative period, continue buprenorphine and use multimodal analgesia, she said. The buprenorphine dose will not provide acute pain relief. Again, because of the alpha-elimination of the drug, splitting the dose into twice-daily dosing can assist with pain control. Consider opioids like fentanyl or hydromorphone, which will be more effective given buprenorphine’s mechanism of action.

At discharge, Dr. Hoffman said, contact the opioid treatment program or provider and inform them of the patient’s discharge plan, including whether the person is being discharged with any additional opioids. Ensure patients have a prescription for or a supply of buprenorphine at home.

This article is from the January 2022 print issue.