Educating Patients Regarding Pain Management and Safe Opioid Use After Surgery

A Narrative Review

Bradley H. Lee, MD; Christopher L. Wu, MD

Disclosures

Anesth Analg. 2020;130(3):574-581. 

In This Article

Providing Information on Pain Management and Opioids: Developing the Solution

Patients undergoing surgery who are prescribed opioids need specific details about medications and their role in managing postoperative pain to guide them on safe and appropriate use (summarized in Table 1).

It may be helpful to clarify the term "opioid" and explain how it refers to a class of prescription pain medications and distinguish this from the term "narcotic" which describes more broadly anything that causes sedation or narcosis including illicit substances.[40] Patients may also recognize generic or brand names of opioids (eg, morphine, oxycodone, Oxycontin [Purdue Pharma LP, Stamford, CT], Percocet [Endo Pharmaceuticals Inc, Malvern, PA], hydrocodone, and Vicodin [Mikart Inc, Atlanta, GA]).

After identifying these medications, it is helpful to explain how they fit into the overall pain management strategy by reviewing the goals of pain control and how opioids are used. This is important because many patients do not have adequate knowledge about pain relief to effectively manage their own pain and may therefore have difficulty with postoperative analgesia.[41,42] Patients need to understand that experiencing pain after surgery is normal; however, the role of pain control is to allow movement and facilitate recovery.[43] Opioids may be used but are limited to pain intensity that interferes with activities and is not covered by nonopioid strategies, and these medications are used for the shortest duration possible. Pain is typically most significant in the initial few days after surgery; however, pain improves over time and fewer opioids are needed.[44,45] Therefore, the goal is to taper and discontinue these medications as early as possible.

Multimodal analgesia is an important concept for managing postoperative pain, and there is increasing evidence that it results in improved pain control after surgery and reduced opioid consumption.[46–50] In fact, recent guidelines on postoperative pain management recommend multimodal analgesia when possible, which is supported by high-quality evidence.[51] Educating patients on utilizing various forms of analgesia apart from opioids will ideally help them to understand the importance of multimodal analgesia and appreciate how addressing different forms of pain processing will improve postoperative analgesia. The various forms of multimodal analgesia may be reviewed including nonopioid analgesics, namely acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, as well as other interventions including meditation, heat, and cold.[47]

A wide range of procedures have become amenable to various forms of regional anesthesia. Regional anesthesia techniques can be utilized for upper extremity, lower extremity, abdominal, thoracic, and breast operations.[52–60] There is mounting evidence that regional anesthesia is effective for improving analgesia and minimizing opioid use postoperatively.[61–65] When regional anesthesia is involved, patients may benefit by receiving information about its use and, in particular, how it improves postoperative analgesia. This will hopefully help them understand that by utilizing regional techniques, fewer opioids may be needed after surgery.

Patients who are prescribed opioids need information on their associated side effects and risks as improved education about these details appears to limit high-risk behaviors and opioid misuse[7,12] (Table 1). It is helpful to review common side effects such as nausea, vomiting, pruritus, sedation, respiratory depression, and constipation[66,67] and for patients to appreciate that side effects may be dose dependent. It is also important for patients to be educated regarding important concepts of addiction, dependence, and tolerance as well as risks associated with these disorders. Concerns for addiction can occur even after only 5 days of use, and the risk increases with longer durations of use.[68] Tolerance resulting in higher doses of medication to achieve the same effect not only makes controlling pain more difficult but also increases the risk of accidental overdose.[67] Finally, in patients using opioids long term, opioid-induced hyperalgesia can increase pain sensitivity and result in abnormal pain perception and increasingly difficult-to-manage pain.[67,69,70]

It is important for patients receiving prescription opioids to receive guidance on safe practices because improved knowledge may reduce potentially risky behaviors associated with opioid use[7,12] (Table 1). Patients need to understand that opioids are taken only as prescribed to avoid misuse and risks associated with misuse. Common examples of opioid misuse include taking opioids as sleep aids, crushing pills for faster onset, and combining medications with alcohol or other sedating medications. Patients with sleep apnea are also at increased risk of opioid-induced respiratory depression[71,72] and therefore need to adhere strictly to Continuous Positive Airway Pressure (CPAP) use while taking opioids. These patients, in particular, may benefit from multimodal analgesia to reduce opioid use and associated postoperative complications.[73]

Finally, all patients require education regarding proper storage and disposal of opioids to limit the risk of opioid misuse, theft, or overdose. Safe handling involves keeping medications out of reach of children, storing medications in the original container locked or hidden away from others, and never sharing medications. Medications are disposed of as soon as they are no longer needed, and options for disposal include drug take-back programs or safe drop sites which can be found online.

If patients are not able to use these options, then they should mix unused medications with an unpalatable substance and disposed in the trash. The Food and Drug Administration (FDA) has also listed certain medications that may be safely flushed down the toilet without posing environmental consequences when take-back programs are not available.[74]

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