Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Abstract

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

Efficacy of transversus abdominis plane block in pain control after general abdominal surgery – a short review of the literature

“…If not well handled, pain can become chronic within 3 to 4 months, being much more difficult to treat, if at all. In consequence, this leads to impaired quality of life, both from a social and economic point of view, particularly through the chronic consumption of opioids [28].…”

Pain management‐related assessment and communication across the care continuum: Consensus of the opioid task force of the island peer review organization pain management coalition

“…A pharmacist, regardless of their practice setting, can focus their efforts on medication reconciliation, assessing patient specific factors to guide pain medication selection and optimization, and identifying opportunities for deprescribing and tapering opioids to support opioid stewardship and aid in efforts to improve communication during TOC 41‐43 . Consistent delivery of pain management must be comprehensive and include collaboration with the patient and interprofessional team to establish goals of therapy and a multimodal treatment plan, screening for ORADEs and OUD risk factors prior to the start of opioid therapy, utilizing evidence‐based pain management strategies, implementation of effective patient monitoring and distribution of naloxone.…”

Complete opioid transition to sublingual Buprenorphine after abdominal surgery is associated with significant reductions in opioid requirements, but not reduction in hospital length of stay: a retrospective cohort study

“…Moreover, in cases of prolonged ileus, the potential for a protracted exposure to significant doses of lipid-soluble opioids may be associated with the development of opioid tolerance [2]. Concurrently, many postoperative patients may find themselves discharged on large doses of opioids for ongoing analgesia, with a proportion continuing such drug therapy because of poorly managed pain, opioid tolerance or dependence, or simply poor opioid stewardship [3]. The resulting complications are part of the 240% increase in hospitalisations and deaths in Australia related to opioid over-use since 2000 [4].…”