Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery

Abstract

This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence. RÉSUMÉ Cette déclaration de consensus fait des recommandations pour la prescription d'analgésiques à la sortie de l'hôpital pour les patients adultes n'ayant jamais pris d'opiacés et qui subissent une intervention chirurgicale non urgente. Elle encourage les prestataires de soins de santé (chirurgiens, anesthésiologistes, infirmières et infirmiers, infirmières et infirmiers praticiens, équipes antidouleur, pharmaciens, professionnels de la santé et stagiaires) à (1) utiliser des traitements non opiacés et à réduire la prescription d'opiacés afin de réduire le nombre de pilules opiacées pouvant être détournées; et (2) à éduquer les patients, ainsi que leurs familles et soignants, sur les options de prise en charge de la douleur après l'opération afin d'optimiser la qualité des soins pour la douleur postopératoire. Ces recommandations s'appliquent aux patients adultes n'ayant jamais pris d'opioïdes et qui subissent une intervention chirurgicale non urgente. Cette déclaration de consensus est destinée à être utilisée par les prestataires de soins de santé impliqués dans la prise en charge des patients opérés et les soins qui leur sont apportés. Un processus Delphi modifié a été utilisé pour parvenir à un consensus sur les recommandations. Tout d'abord, les auteurs ont procédé à une de la portée de la littérature afin de déterminer les pratiques exemplaires actuelles et les lignes directrices existantes. À partir de la littérature disponible et de l'expertise des ...

Postoperative Pain Management

“…54 However, the effect was not identified for low-dose NSAIDs (diclofenac <125 mg/ day, ketorolac 120 mg/day) taken for less than 2 weeks, which has been confirmed in additional studies. [55][56][57] Nonetheless, spine surgeons have erred on the side of caution and prefer to avoid NSAIDs postoperatively. 58 Additionally, within patients undergoing colorectal surgery, a meta-analysis (24 studies, n = 31,877) showed an increased risk for anastomotic leaks (OR 1.73, 95% CI 1.31 to 2.29) with the use of NSAIDs.…”

Important considerations with respect to reducing the transition from acute to persistent postoperative pain

“…Patients should be made aware that scheduled acetaminophen and NSAIDs are first line for the management of post surgical pain, with opioids only being added if there is a need for further analgesia. Standard opioid prescribing should be tailored to the expected functional recovery of each surgical intervention with part-fills used to avoid excessive left-over opioid medications [8]. Nonpharmacological coping strategies should be reinforced and information regarding the appropriate use, storage and disposal of remaining opioid medications (i.e.…”

“…Nonpharmacological coping strategies should be reinforced and information regarding the appropriate use, storage and disposal of remaining opioid medications (i.e. return to the pharmacy) should be provided [8]. A meta-analysis of 44 studies (13,068 patients) published in 2020 showed that 61% of opioids are left unused after surgery [12].…”

“…Discharge opioid prescriptions should be individualized for each patient and based on the last 24 hours of opioid consumption. Prediction models can be used to help anticipate the duration and total requirements of the opioid medication [8]. If a patient did not require opioid analgesia in the last 24 hours of admission, then an opioid should not be prescribed at discharge.…”

“…Patients should be screened perioperatively for both risk factors of PPSP and persistent opioid use after surgery. A comprehensive plan should be implemented for these patients, including opioid-sparing techniques and a postoperative follow-up schedule and weaning plan [8].…”