Postsurgical Pain

Pain Following Surgery May Vary Quite Widely in Severity

Postsurgical undertreatment of pain has been linked to reduced quality of life, surgical complications, prolonged rehabilitation, and development of chronic pain.[1] Thus, in certain situations, the benefits of a limited course of opioids may outweigh the risks if pain management is inadequate with nonopioid therapies.

Patients of All Ages Frequently Take Fewer Opioids Than the Amount Prescribed Postsurgically

However, multiple studies have found that patients of all ages frequently take fewer opioids than the amount prescribed postsurgically and in some cases do not take any prescribed opioids at all, [2][7] resulting in excess opioid pills that are accessible to others, raising risks of misuse and overdose.

Perioperative Opioid Prescribing has been Associated with Persistent Opioid Use

Also, perioperative opioid prescribing has been associated with persistent opioid use after surgery,[8][10] particularly with a larger prescription amount, highlighting that risks associated with opioids may extend well beyond the immediate postoperative period. Of note, one institution found that decreased opioid prescribing in the postsurgical setting was not associated with a decrease in clinician satisfaction ratings.[11]

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Patients of all ages frequently take fewer opioids than the amount prescribed after surgery.

Treatment Recommendations

and Michigan OPEN Acute Care Opioid Treatment and Prescribing Recommendations: Summary of Selected Best Practices, Surgical Departmentpdf iconexternal icon

“For patients discharged from surgical department with an opioid prescription:

  • Non-opioid therapies should be encouraged as a primary treatment for pain management (e.g., acetaminophen, ibuprofen).
  • Non-pharmacologic therapies should be encouraged (e.g., ice, elevation, physical therapy).
  • Do NOT prescribe opioids with other sedative medications (e.g., benzodiazepines).
  • Short-acting opioids should be prescribed for no more than 3-5–day courses (e.g., hydrocodone, oxycodone).
  • Fentanyl or long-acting opioids such as methadone [and] OxyContin … should NOT be prescribed to opioid naïve patients.”

Michigan OPEN surgery-specific opioid prescribing recommendations are regularly updated based on clinical data on opioid use.

“Evidence-Based Duration of Opioid Prescriptions on Discharge Following Surgery (select guidance; please refer to the guideline for its complete recommendations)

  • Type I – Expected rapid recovery (procedures such as laparoscopic appendectomy, inguinal hernia repair, carpal tunnel release, thyroidectomy, among other surgeries)
    • Prescribe non-opioid analgesics (e.g., NSAIDsexternal icon and/or acetaminophen) and non-pharmacologic therapies as first-line therapy.
    • If opioids are necessary, prescribe ≤3 days (e.g., 8 to 12 pills) of short-acting opioids in combination with an NSAID or acetaminophen for severe pain. Prescribe the lowest effective dose strength.
  • Type II – Expected medium term recovery (procedures such as anterior cruciate ligament [ACL] repair, rotator cuff repair, discectomy, laminectomy, open or laparoscopic colectomy, among other surgeries)
    • Prescribe non-opioid analgesics (e.g., NSAIDsexternal icon and/or acetaminophen) and non-pharmacologic therapies as first-line therapy.
    • Prescribe ≤7 days (e.g., up to 42 pills) of short-acting opioids for severe pain. Prescribe the lowest effective dose strength.
    • For those exceptional cases that warrant more than 7 days of opioid treatment, the surgeon should re-evaluate the patient before a third prescription and taper off opioids within 6 weeks after surgery.
  • Type III – Expected longer term recovery (procedures such as lumbar fusion, knee replacement, hip replacement, abdominal hysterectomy, axillary lymph node resection, among other surgeries)
    • Prescribe non-opioid analgesics (e.g., NSAIDsexternal icon and/or acetaminophen) and non-pharmacologic therapies as first-line therapy.
    • Prescribe ≤14 days of short-acting opioids for severe pain. Prescribe the lowest effective dose strength.
    • For those exceptional cases that warrant more than 14 days of opioid treatment, the surgeon should re-evaluate the patient before refilling opioids and taper off opioids within 6 weeks after surgery.”

[1] Garimella V, Cellini C. Postoperative Pain Control. Clin Colon Rectal Surg. 2013 Sep;26(3):191-6.

[2] Lovecchio F, Premkumar A, Stepan JG et al. Opioid Consumption Patterns After Lumbar Microdiscectomy or Decompression. Spine (Phila Pa 1976). 2019 Nov 15;44(22):1599-1605.

[3] Ngombu S, Hooks A, Rock AN et al. Comparison of Opioid Prescription Patterns and Consumption Following Otologic Surgery. Otol Neurotol. 2019 Oct 31.

[4] Choo S, Nogan S, Matrka L. Postoperative Opioid Prescribing and Consumption Patterns after Tonsillectomy. Otolaryngol Head Neck Surg. 2019 Jul 30

[5]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. doi: 10.1097/SLA.0000000000001993.

[6] Thiels CA, Anderson SS, Ubl DS et al. Wide Variation and Overprescription of Opioids After Elective Surgery. Ann Surg. 2017 Oct;266(4):564-573. doi: 10.1097/SLA.0000000000002365.

[7] Horton JD, Munawar S, Corrigan C et al. Inconsistent and Excessive Opioid Prescribing after Common Pediatric Surgical Operations. J Pediatr Surg. 2018 Jul 7. pii: S0022-3468(18)30431-7. doi: 10.1016/j.jpedsurg.2018.07.002.

[8] Brescia AA, Waljee JF, Hu HM et al. Impact of Prescribing on New Persistent Opioid Use After Cardiothoracic Surgery. Ann Thorac Surg. 2019 Oct;108(4):1107-1113.

[9] Young JC, Dasgupta N, Chidgey BA, Jonsson Funk M. Postsurgical Opioid Prescriptions and Risk of Long-term Use: An Observational Cohort Study Across the United States. Ann Surg. 2019 Aug 9.

[10] Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use after Minor and Major Surgical Procedures in US Adults. JAMA Surg.2017;152:e170504.

[11] Louie CE, Kelly JL, Barth RJ Jr. Association of Decreased Postsurgical Opioid Prescribing With Patients’ Satisfaction With Surgeons. JAMA Surg. 2019 Oct 16.