From 1999 to 2014, more than 165,000 people in the U.S. died from overdoses related to prescription opioids.1 Improved opioid prescribing practices can lead to safer and more effective acute and chronic pain management for surgical patients while reducing the number of people who misuse, abuse, or overdose from these drugs. One of the most important steps to ensure safe prescription opioid use for outpatients is to identify whether they will require a course of postoperative pain medication or will require a multidisciplinary approach to pain management.
Up to 25 percent of patients receiving long-term opioid therapy in a primary care setting struggle with addiction.2 Determining if patients have been exposed to narcotics in the past and whether they have developed a tolerance for narcotics is helpful in establishing patient-physician trust and rapport, as well as determining the potential for misuse, abuse, or overdose.
Understanding the patient population within the surgeon’s geographic practice area is important to determine which patients may potentially seek increased opioid prescriptions versus those who choose not to use narcotic pain management due to social, spiritual, or religious beliefs. Patients who choose to forgo narcotics for perioperative pain management may sacrifice adequate pain control, resulting in increased length of stay and higher risk of perioperative morbidity.3 An opportunity to better understand and educate these patients may lead to improved pain control, as well as insight into the unique patient populations that struggle with the challenge of achieving adequate pain control postoperatively, particularly when previous opioid dependence has been an issue.
Opportunities for patient education
As a result of the rise in opioid-associated deaths and the number of adults regularly using prescription opioid medication, surgeons must now serve as gatekeepers of iatrogenic opioid dependence, especially considering that surgeons reportedly prescribe nearly 37 percent of the total opioid pain medication prescribed to noncancer patients, second only to pain medicine specialists.4,5 These statistics show that health care professionals are in a unique position to optimize pain management strategies that will decrease frequent and prolonged opioid use. Patient education reportedly decreases the need for postoperative opioid medication and improves patient satisfaction.6,7 Every patient encounter is a chance to educate patients about pain management expectations, modalities of pain control, and the risks of opioid pain medications. Interdisciplinary strategies that incorporate the surgeon, pain management specialists, nurses, physical and occupational therapists, ancillary staff, families, and other patient support systems are ideal approaches to controlling patient pain while minimizing opioid use.8
Patient education regarding pain control should begin at the initial clinical evaluation and consultation and should be reinforced during the preoperative visit. Patients should be informed about their procedure, the degree and extent of expected perioperative pain, recovery time, and expectations for pain management in the outpatient setting during recovery.9 Patients should be counseled to expect adequate pain control based on function, such as the ability to sleep, ambulate, and eat. Additionally, patients should be reminded that zero pain is an unrealistic expectation.10 Hill and colleagues recommend setting patient expectations regarding the number of opioid pills that they will require and subsequently receive to decrease the number of pills prescribed postoperatively.11 Patient education is best provided in a personal, face-to-face encounter with culturally and linguistically appropriate written, video, and web-based educational materials.9
The preoperative visit also allows the surgeon to assess the patient’s history for dependence or tolerance to opioids and previous or current use disorders that may increase the need for opioid medications in the postoperative period. For example, patients who chronically use opioids for long-term pain control frequently require special attention for controlling current postsurgical pain and for addressing the continued management of their chronic pain. Some patients who have struggled with addiction in the past may be hesitant to use opioids due to fear of recidivism, and their concerns often require the attention of providers trained in this area of pain management. If such concern exists, a preoperative visit with the anesthesiologist is warranted to discuss multimodal therapies, such as nerve blocks, neuraxial anesthesia, and other alternative pain management strategies.12
The postoperative period is when pain control is a priority and is a good time to revisit patient expectations. Educating patients about their multimodal pain control plan that will include nonopioid medications often helps in building rapport and establishing more defined goals for pain management.13 The postoperative consult is the time to remind patients that eradicating pain is an unachievable goal and that pain control should be measured based on their ability to perform activities of daily living in the postoperative setting. In addition, patients should be counseled on how and when to take their medication.
For patients who need to use opioid medications for more than two weeks, a tapering plan should be implemented, decreasing the discharge dose by 20 to 25 percent every one to two days to abate symptoms of severe withdrawal.14 Counseling patients on how to take pain medications (for example, with or without food) and how to manage the side effects should be included in the discharge instructions. During the postoperative visit, patients should also be warned to avoid alcohol and other central nervous system depressants to avoid accidental overdose.9
If surgeons are committed to ending the opioid epidemic, we must not only decrease the number of opioid medications prescribed, but also educate our patients to properly and safely dispose of excess opioid medications. More than 70 percent of pills prescribed to general surgery patients in the acute postoperative period go unused, but only 9 percent of patients dispose of their medications according to U.S. Food and Drug Administration (FDA) guidelines.11 The FDA recommends disposing of opioid pills at Drug Enforcement Administration-approved collection sites, community-based drug “take-back” programs, flushing them down the toilet, placing them in a sealable plastic bag, or dissolving the pills in water and mixing them with compostable materials (such as coffee grounds) and placing the mixture in a sealable bag before placing in the trash.15 Surgeons should provide patients with written instructions on proper disposal guidelines prior to discharge, for their reference at home.
These same recommendations for opioid education apply to patients who receive care from subspecialty surgeons. However, the unique circumstances of acute, postoperative pain in children, oncology patients, and patients with inflammatory bowel disease (IBD) warrant special consideration. In some instances, the patient’s preoperative anxiety may preclude proper attention to opioid counseling. Providers should tailor the timing of their approach to best fit each patient’s needs. It is important to include the individuals who will assist in caring for the patient upon discharge in any counseling session with the patient.16
Patient education should apply a multidisciplinary approach, and the surgeon should not underestimate the effect of other team members in counseling the patient on pain management. For example, the nurse or team pharmacist responsible for the last interaction with the patient prior to discharge has an opportunity to expand the patient’s knowledge and understanding of appropriate opioid use, weaning, storage, and disposal. It is crucial to remind all members of the health care team that their interactions and time with patients make a difference.
While the number of overall opioid prescriptions written for children is relatively low, rates have nearly doubled in the last decade.17 Galinkin and colleagues suggest that dependence, but not necessarily addiction, can occur in children after just one week of opioid use.18 After discharge, the parents or guardians are responsible for dosing and administration of pain medication to children, and it is imperative that health care providers educate parents regarding the balance between pain control and overuse. As with other surgical settings, when possible, this counseling should begin preoperatively and include a multidisciplinary approach.
The safe storage and disposal of opioids is a crucial aspect of patient education, especially in settings where children may access them. With one-fifth of unintentional opioid overdoses in children younger than six years old occurring due to the ingestion of a medication that was prescribed for an adult, proper guardian education about the storage and disposal of opioids is paramount.19 While these conversations are critical in the pediatric surgery setting, they are equally as important to have with any patient who will be prescribed opioids and resides with young children.19
Special consideration should be given to adolescent patients, especially those who may be directly managing their own medication administration. Studies have shown that depression and preoperative marijuana use are associated with postoperative opioid misuse among adolescents.20,21 Preoperative screening for these factors is recommended so that providers can offer necessary resources to mitigate the risk of long-term abuse.
Cancer patients experience pain at exceedingly high rates;22 an estimated 25 percent of this pain is secondary to treatment, including operative procedures.23 Chronic opioid use in these patients can cause decreased efficacy, which complicates control of acute, operative pain.22 It is vital that patients understand that full disclosure of their baseline opioid use is critical to safe, adequate postoperative pain management, as well as the prevention of withdrawal symptoms.24 This conversation should occur preoperatively and involve a nonjudgmental approach to elicit honest patient responses.22 Guidance regarding perioperative medication use should be provided, including instructions to take pain medication at home the morning of surgery and information regarding the continued use of the transdermal patch, if applicable.22,24
It is important not only to educate patients about pain medication use, but also about the anticipated level of pain control, reassuring them that the ultimate goal is to adequately control their acute, operative pain rather than mitigate their existing symptoms.22 However, in some circumstances, surgical treatment may relieve preoperative pain, such as in cases of pain due to compression.23 Patients should, therefore, have a clear understanding that their symptoms will be reevaluated after postoperative healing to assess whether their baseline opioid requirements have changed. Throughout this process, it is important not to lose sight of the ultimate goal—pain control. Published research suggests that cancer patients overall have very low rates of opioid abuse; fear of misuse, by either the patient or provider, should not preclude therapeutic dosing.23
Colorectal surgery: IBD
Opioid counseling in patients with IBD poses a unique challenge for health care providers. Studies suggest that these patients use preoperative opioids at high rates and are at increased risk for misuse.25 This risk appears to be more significant for patients with Crohn’s disease than ulcerative colitis.26,27 High rates of narcotic usage for these patients are an independent predictor of increased readmissions; emergency department visits; and high treatment charges, defined as more than $30,000 in the year after the index admission.28 Increased rates of abuse for patients with IBD also are seen in patients with underlying psychiatric disorders and chronic functional abdominal pain syndromes.29 Although the literature regarding operative pain control in this population is scarce, it is reasonable to assume that, as in other subsets of chronic pain patients, postoperative pain control and opioid withdrawal may be challenging, and adverse effects can be mitigated through proper assessment and counseling. The surgeon should be diligent and educate the patient both preoperatively to discuss realistic expectations of postoperative symptoms, as well as prior to discharge to discuss the following: weaning the patient off of opioids; managing opioid use; caring for unpredictable gastrointestinal function frequently encountered with IBD; and how to contact their provider if problems arise in the outpatient setting. Postoperative opioid use should also be discussed at follow-up appointments and may involve a joint approach between the surgeon and gastroenterologist.
Tools of the trade and patient resources
Making patient educational tools and information available in patient waiting rooms and the office setting can provide an icebreaker to start the conversation about opioids. It is ideal to include culturally sensitive, inclusive images in these materials, as well as figures and text that are easy to comprehend. Table 1 is an example of a basic chart with commonly used opioids that physicians can use to develop a pain management plan with a patient.
Table 1. Chart template for educating patients on opioid options
|Generic name||Brand name||Route of administration||Common dose||Length
|Oxycodone (immediate release)||Oxycodone||Orally||5 mg||4–6 hours|
|Oxycodone/acetaminophen||Percocet||5 mg oxycodone/
325 mg acetaminophen
|5 mg hydrocodone/
325 mg acetaminophen
|Hydrocodone||Hycodan||5 mg hydrocodone|
Arymo (extended release)
|Orally||15 mg||12 hours|
|5 mg||8 hours|
|Oxycodone (extended release)||OxyContin||10 mg||12 hours|
transdermal (skin patch)
|No recommended dose||Dependent on route of administration|
Implementation of a system-wide initiative within the U.S. Department of Veterans Affairs (VA) has been associated with reductions in outpatient prescribing of risky opioid regimens.30 VA initiatives have successfully shown that patient education programs offer easily accessible and useful information for veterans and patients to more safely use prescription opioids. Furthermore, facilitating patient access to educational materials that are easy to understand increases the likelihood that patients will use opioids safely. The Opioid Safety Initiative Toolkit, developed by a panel of multidisciplinary experts and available from the VA, provides a clear explanation of the pathway between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. These guidelines provide health care providers with a framework to evaluate, treat, and manage the individual needs and preferences of patients with chronic pain who are on or are being considered for long-term opioid treatment.31 The Opioid Safety Initiative Toolkit is accessible online and offers guidelines for both the provider and the patient.
Given the mounting body of research detailing the lack of benefit and potential harm of long-term opioid therapy, it is imperative that the surgeon strive to educate patients about the correct use of these drugs. Building rapport to create a dynamic and open physician-patient relationship and keeping lines of communication open to discuss side effects, efficacy, and tapering regimens is crucial to prescribing opioids safely. Providing accessible educational materials to patients regarding prescriptions, as well as using a multidisciplinary approach to prescribe and, ultimately, taper opioid medications, is critical to optimizing pain management in the postoperative period.
- Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large U.S. health care system. Addiction. 2010;105(10):1776-1782.
- Banta-Green CJ, Merrill JO, Doyle SR, Boudreau DM, Calsyn DA. Opioid use behaviors, mental health and pain—development of a typology of chronic pain patients. Drug Alcohol Depend. 2009;104(1-2):34-42.
- Zuccaro SM, Vellucci R, Sarzi-Puttini P, Cherubino P, Labianca R, Fornasari D. Barriers to pain management: Focus on opioid therapy. Clin Drug Investig. 2012;32 (Suppl 1):11-19.
- Waljee JF, Li L, Brummett CM, Englesbe MJ. Iatrogenic opioid dependence in the United States: Are surgeons the gatekeepers? Ann Surg. 2017;265(4):728-730.
- Olsen Y. The CDC guideline on opioid prescribing: Rising to the challenge. JAMA. 2016;315(15):1577-1579.
- Angioli R, Plotti F, Capriglione S, et al. The effects of giving patients verbal or written pre-operative information in gynecologic oncology surgery: A randomized study and the medical-legal point of view. Eur J Obstet Gynecol Reprod Biol. 2014;177:67-71.
- Kruzik N. Benefits of preoperative education for adult elective surgery patients. AORN J. 2009;90(3):381-387.
- Nielsen S, Campbell G, Peacock A, et al. Health service utilisation by people living with chronic non-cancer pain: Findings from the Pain and Opioids IN Treatment (POINT) study. Aust Health Rev. 2015;40(5) 490-499.
- Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-157.
- Gawande AA. It’s time to adopt electronic prescriptions for opioids. Ann Surg. 2017;265(4):693-694.
- Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017;265(4):709-714.
- Vadivelu N, Kai AM, Kodumudi V, Zhu R, Hines R. Pain management of patients with substance abuse in the ambulatory setting. Curr Pain Headache Rep. 2017;21(2):9.
- Wilson M, Roll JM, Corbett C, Barbosa-Leiker C. Empowering patients with persistent pain using an Internet-based self-management program. Pain Manag Nurs. 2015;16(4):503-514.
- Gordon DB, de Leon-Casasola OA, Wu CL, Sluka KA, Brennan TJ, Chou R. Research gaps in practice guidelines for acute postoperative pain management in adults: Findings from a review of the evidence for an American Pain Society Clinical Practice guideline. J Pain. 2016;17(2):158-166.
- Traynor K. Some unused narcotics should go down the drain, FDA says. Am J Health Syst Pharm. 2009;66(23):2070-2072.
- Costello M. Prescription opioid analgesics: Promoting patient safety with better patient education. Am J Nurs. 2015;115(11):50-56.
- Groenewald CB, Rabbitts JA, Gebert JT, Palermo TM. Trends in opioid prescriptions among children and adolescents in the United States: A nationally representative study from 1996 to 2012. Pain. 2016;157(5):1021-1027.
- Galinkin J, Koh JL, Committee on Drugs, Section on Anesthesiology and Pain Medicine, American Academy of Pediatrics. Recognition and management of iatrogenically induced opioid dependence and withdrawal in children. Pediatrics. 2014;133(1):152-155.
- Voepel-Lewis T, Zikmund-Fisher BJ, Smith EL, Redman RW, Zyzanski S, Tait AR. Parents’ analgesic trade-off dilemmas: How analgesic knowledge influences their decisions to give opioids. Clin J Pain. 2016;32(3):187-195.
- Edlund MJ, Forman-Hoffman VL, Winder CR, et al. Opioid abuse and depression in adolescents: Results from the National Survey on Drug Use and Health. Drug Alcohol Depend. 2015;152:131-138.
- Monnat SM, Rigg KK. Examining rural/urban differences in prescription opioid misuse among U.S. adolescents. J Rural Health. 2016;32(2):204-218.
- Huxtable CA, Roberts LJ, Somogyi AA, MacIntyre PE. Acute pain management in opioid-tolerant patients: A growing challenge. Anaesth Intensive Care. 2011;39(5):804-823.
- Christo PJ, Mazloomdoost D. Cancer pain and analgesia. Ann N Y Acad Sci. 2008;1138(9):278-298.
- Brill S. Managing surgical pain in long-term opioid patients. J Pain Palliat Care Pharmacother. 2013;27(2):185-187.
- Cross RK, Wilson KT, Binion DG. Narcotic use in patients with Crohn’s disease. Am J Gastroenterol. 2005;100(10):2225-2229.
- Kaplan MA, Korelitz BI. Narcotic dependence in inflammatory bowel disease. J Clin Gastroenterol. 1988;10(3):275-278.
- Buckley JP, Kappelman MD, Allen JK, Van Meter SA, Cook SF. The burden of comedication among patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013;19(13):2725-2736.
- Limsrivilai J, Stidham RW, Govani SM, Waljee AK, Huang W, Higgins PD. Factors that predict high health care utilization and costs for patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol. 2017;15(3):385-392 e2.
- Makharia GK. Understanding and treating abdominal pain and spasms in organic gastrointestinal diseases: Inflammatory bowel disease and biliary diseases. J Clin Gastroenterol. 2011;45(8) Suppl:S89-93.
- Lin LA, Bohnert ASB, Kerns RD, Clay MA, Ganoczy D, Ilgen MA. Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans. Pain. 2017;158(5):833-839.
- Midboe AM, Lewis ET, Paik MC, et al. Measurement of adherence to clinical practice guidelines for opioid therapy for chronic pain. Transl Behav Med. 2012;2(1):57-64.