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Patients
Preparing for Surgery
Pain after surgery is normal and expected. You may hear it called acute pain, because, while it can cause considerable discomfort, it usually begins to get better a few days after surgery. Before surgery, talk with your surgeon about any medications or substances you take as these may impact your pain control. Ask your surgeon what type of pain is expected after surgery and what you should do to control your pain. Options to control pain may include using over the counter (OTC) medications, non-medication options and if prescribed, opioid medications. If you are prescribed an opioid medication, it is important to know the risks, potential dangers and side effects, and how to minimize risk to yourself and others.
Each person recovers from surgery in their own way, and someone who has the same procedure might have a completely different experience of pain. Pain after surgery is normal and tells you that your body is healing, and you might need to balance activity with rest. It is an uncomfortable but natural part of recovery. While everyone feels pain differently, typically surgery pain is the worst during the first 2-3 days after and then begins to get better.
The GOAL OF PAIN MANAGEMENT is for you to do activities of daily living like:
Eat
Sleep
Breathe deeply
Walk
Pain may be well-controlled with a schedule of over the counter (OTC) medications like acetaminophen (Tylenol®) and ibuprofen (Motrin®, Advil®). Adding non-medication options to your pain management plan can help to successfully treat pain.
Review with your surgeon and ask for recommendations for how to take your medications prior to surgery including:
Alcohol
Tobacco
Antidepressants (like Prozac® or Celexa®)
Sedatives (like Ambien® or Seroquel®)
Benzodiazepines (like Valium®, Xanax®, or Klonopin®)
Stimulants (like Adderall®, Ritalin®, or Vyvanse®)
Opioids (like Oxycodone®, Vicodin®, or Norco®)
Any other substances (like Marijuana, Crack/Cocaine, Methamphetamine)
Pain Expectations
Ask your surgeon about:
What type of pain you will have
How long you should expect to have pain
What you should do if your pain is not controlled
Non-Medication Options
There are many non-medication options that play an important role in managing pain and reducing anxiety. You can use these methods, along with the medications your surgeon has recommended, to help manage pain. Using these methods may allow you to decrease use of opioids or other medications and avoid their side effects.
Mindfulness or Meditation
Music
Books
Calm breathing, like belly breathing or square breathing, can help to relax muscles that are tense because of pain or anxiety. This is called Mindful Breathing. You can also focus your mind and visualize a particular place you enjoy that makes you feel calm, relaxed, and comfortable.
Music may be very comforting when you are experiencing pain or discomfort. Listening to music, singing, or writing songs can help to lessen pain and anxiety.
Before surgery, take time to select a few books that you would like to read while you are recovering. This can help you to feel relaxed and distraction from pain after surgery.
Sleep or Relaxation
Ice or Heat
Compression
Take time during your recovery to rest and relax. Sleep helps the body heal.
Talk to your surgeon to determine if ice or heat would be helpful to your recovery.
Talk to your surgeon to determine if compression of the surgery area would be helpful to your recovery. Using an ‘abdominal binder’ after surgery can provide comfort especially when moving around.
Short walks
Taking a short walks after surgery is so important! Walking helps to:
-Get blood flowing in your body which helps you heal and reduces risk of developing blood clots
-Regain your strength and mobility before surgery
-Reduce constipation
-Improve mood and anxiety
Using Over-the-Counter (OTC) Medication
Using medications like ibuprofen (Motrin or Advil) and acetaminophen (Tylenol), that you can purchase at your local pharmacy, can be very effective at managing your pain after surgery. Each works in different ways to manage pain and can be taken together at the same time.
Ask your surgeon:
If you can use OTC medications like Motrin or Tylenol after surgery to manage pain
What dose and how often to take
Example: For the first 3-5 days after surgery, take Tylenol and Motrin at regularly, scheduled times and then as needed as pain improves
Sample schedule and doses for OTC medications:
Time
Medication (Dose)
9 AM
TYLENOL (1000mg)
MOTRIN (600mg)
3 PM
TYLENOL (1000mg)
MOTRIN (600mg)
9 PM
TYLENOL (1000mg)
MOTRIN (600mg)
Give the dose your doctor recommends: It is important to use the dose your surgeon recommends even if it is different from the dose listed on the medication bottle.
Opioid Use for Surgical Pain
What is an Opioid?
An opioid is a prescription pain medication that may be prescribed by your surgeon to use after surgery for pain control.
Most Common Opioids
Generic Name
Brand Name
Codeine
Tylenol® #3* or #4*
Fentanyl
Duragesic®
Hydrocodone
Vicodin®*, Norco®*
Hydromorphone
Dilaudid®
Methadone
Methadose®
Morphine
MS Contin®, Kadian
Oxycodone
Percocet®*, OxyContin®
Oxymorphone
Opana®
Tramadol
Ultram®, Ultracet®*
*Contains acetaminophen (Tylenol®). Use caution if you’re taking acetaminophen.
Opioid Use
Because of their risks, opioids are not usually the starting point to manage acute pain after surgery. OTC medications like Tylenol and Motrin and non-medication strategies should be tried first to manage pain.
If an opioid medication is prescribed to you by your surgeon, it is usually only for managing severe breakthrough pain that is not controlled by OTC medications and non-medications strategies.
Even if you are using an opioid medication for breakthrough pain, you should still continue to use the OTC medications recommended by your surgeon and non-medication strategies.
As your pain gets better, stop using or use fewer opioids at a time.
Do not use opioids at the same time as alcohol, benzodiazepines, muscle relaxers, sleep aides, or other medications that can cause sleepiness.
If you are pregnant or planning to become pregnant, using opioid medications can cause harm to a fetus, including neonatal abstinence syndrome.
Talk to your Surgeon about a prescription for Naloxone which is a medication that temporarily reverses the dangerous effects of an opioid overdose.
Side Effects from Opioids
Nausea and/or vomiting
Constipation (difficulty having a bowel movement)
Itching
Sleepiness
Slowed Breathing
Impaired motor skills, thinking or judgment. Teens should not drive while using an opioid.
Contact your surgeon if you notice any of these side effects.
Risks of Using Opioids
Opioids have real risks
Anyone who uses an opioid, even for just a short time, is at risk for dependence, tolerance, misuse, addiction, and overdose. This risk may be higher in individuals with a history of:
Substance use disorder
Tobacco use disorder
Mental illness
Long-term (chronic) pain
Sleep apnea or breathing problems
Taking opioids for longer than a few days or more often than prescribed
Tolerance
When an opioid no longer has the same effect on your pain as it first did, which means you need a higher dose to control pain. For example, if you are taking an opioid which first worked well for pain, and then later it doesn’t work as well, it does not always mean the pain is worse. Instead, you may have become tolerant to the opioid.
Dependance
When your body has started to rely on the opioid to function. This can happen even with using an opioid for a short time period, but the longer you take an opioid, the higher the risk. This is one reason why it is important to use an opioid for as short a time as possible. Suddenly stopping an opioid when a person is dependent causes symptoms of withdrawal, such as muscle aches, yawning, runny nose and tearing eyes, sweating, anxiety, difficulty sleeping, nausea/vomiting, and/or diarrhea.
Misuse
When you take the opioid you were prescribed at a higher dose, more often, or for reasons other than which it was prescribed.
Addiction
When you develop a brain disease known as Opioid Use Disorder (OUD). People with this condition seek and use opioids even though they are causing them harm.
Overdose
When you take a dose of medication that is too high for them. This affects breathing and can cause your child to stop breathing.
Diversion
When anyone other than you gets and uses the medication that was prescribed to you. This can happen when you do not safely dispose of an opioid or leave it unattended. Diversion is dangerous because it can lead to misuse, overdose and/or opioid use disorder in others. Sharing or selling an opioid is a felony in the state of Michigan.
Overdose and Death
Opioids can cause slowed breathing and lead to overdose and death. Discuss the following signs and symptoms of an overdose with your family and friends.
Cannot be awakened or are unable to speak
Vomiting or making gurgling noises
Limp body that may seem lifeless
Fingernails or lips turned blue/purple
Extremely pale or feels clammy to the touch
Talk to your surgeon about a prescription for Naloxone which is a medication that can temporarily reverse the dangerous effects of an opioid overdose. Learn more about this medication with OPEN’s Naloxone Initiative.
Tell your doctor about any other medications you are taking and if you have a history of opioid misuse or addiction, depression or anxiety, or a family history of addiction.
Do not use opioids along with antihistamines such as Benadryl or sleep medications.
Only use the opioid medication for the reason, dose, and frequency that it was prescribed, and use it for the shortest possible time period. If you do not need it, don’t use it and dispose of it properly.
Write down what medications you are taking and when. This will help you be sure you’re using the medication only as prescribed.
Double-check dosing to make sure you’re taking only the amount prescribed.
Watch for signs of side effects or complications, and if you notice them, contact your provider. Inform your support person(s) if you are taking an opioid, signs and symptoms of an overdose, and if you have naloxone to reverse an overdose.
Do not share your opioid with anyone else. It is a prescription only for you.
Prescription size was the strongest predictor of patient consumption3
Evidence-based opioid prescribing guidelines for the perioperative period are needed to enable tailored prescribing for patients and reduce excess opioid pills within communities4
No Correlation between patient satisfaction scores and amount of opioid prescribed5
Prescribing more opioids does not improve patient satisfaction
Patients who were prescribed fewer opioids reported using fewer opioids with no change in pain scores6
Prescribers can feel empowered to reduce their initial opioid prescription without impacting patient satisfaction5
No Correlation between probability of refill and amount of opioid prescribed7
Prescribing fewer opioids initially does not correlate with an increase in refill requests
Prescribers could prescribe smaller opioid prescriptions without influencing the probability of a refill request7
Implementation of evidence-based prescribing guidelines reduced post-laparoscopic cholecystectomy opioid prescribing by 63% without increasing the need for medication refills6
6-10% of surgical patients develop new persistent opioid use8,9,10
New persistent opioid use is one of the most common surgical complications
Many patients continue to use their opioids for reasons other than surgical pain9,10
New persistent opioid use after surgery is an underappreciated surgical complication that warrants increased attention8,9,10
Prescribe acetaminophen and NSAIDs, unless patients have contradictions or high risk adverse effects.
Giving families a prescription helps them understand these are the first-line medications for pain management. Refer to the OTC Quick Reference Sheet
Prescribing codeine or tramadol. Due to pharmacogenetic differences, codeine and tramadol are poor choices for pain management and should not be prescribed
If prescribing opioids is indicated, then follow OPEN's Acute Care Opioid Prescribing Recommendations
Prescribing fentanyl or long-acting opioids (e.g. OxyContin®)
Access the prescription drug monitoring program (PDMP) prior to prescribing controlled substances schedules 2-5, in compliance with state law
Prescribing opioids that contain acetaminophen (e.g. Norco®, Vicodin®, Percocet®) to minimize risk of acetaminophen overdose
Consider co-prescribing naloxone to patients on high doses of opioids or Medications for Opioid Use Disorder
Prescribing opioids with other sedative medications (e.g., benzodiazepines, skeletal muscle relaxants)
Educate
Educate patients and families:
Acetaminophen and NSAIDs should be used together as first-line medications for postoperative pain in surgical patients, unless patients have contraindications or high risk of adverse effects
Use of prescription opioids ONLY to manage severe breakthrough pain that is not relieved by acetaminophen and NSAIDs
Pain expectations and how to taper opioid use as pain improves
Pain usually peaks and then improves after the first 2-3 days following surgery
The risks and side effects of opioid medications (sedation, respiratory depression, dependence, withdrawal, addiction, overdose)
Coordinate with anesthesia, and consider nerve block, local anesthetic catheter or an epidural when appropriate
Connect with the patient’s primary care provider and/or usual prescriber with information about the patient’s operative procedure and the plan for management of acute postoperative pain
If the patient screens positive for risk of SUD, consult an addiction medicine specialist
First-Line Medications for Pain Control
Prescribe Acetaminophen and NSAIDs*
Since acetaminophen and ibuprofen are available over the counter and don’t require a prescription for patients to use, patients and their caregivers often do not receive instructions on how to use them after surgery. The packaging instructions for acetaminophen and ibuprofen provide minimal dosing and recommend as-needed use. If these instructions are followed, patients may be underdosed and inadequately addressing their pain. In addition, if patients were prescribed an opioid, they may think this is the first medication they should use for their pain, not understanding that acetaminophen and ibuprofen often provide adequate pain relief when appropriately dosed and that an opioid may not be needed.
*Unless contraindicated
Your Guidance Can Make a Difference
Even though available OTC, acetaminophen and ibuprofen can be sent electronically as prescriptions to a patient’s pharmacy. When acetaminophen and ibuprofen are written as prescriptions and instructions on how to use them are provided, patients and caregivers then have clear information regarding dosing and understand these are the first-line medications for pain management. Some insurance companies may cover the cost of these medications when they are written as a prescription.
How to dose Acetaminophen
Medication
Usual Dose
Max Daily Dose (mg)
Common OTC Formulations
Acetaminophen
1000mg three to four times per day
4000mg
Tablet: 325mg or 500mg
Capsule: 325mg or 500mg
Oral solution: 160mg/5mL
Extended release tablet: 650mg
Caution should be observed in patients with liver disease, active alcohol use, and G6PD deficiency
Acetaminophen overdose may occur with 5-6 grams daily for prolonged use (6-8+ weeks) or acute ingestion of at least 7.5 grams
How to dose NSAIDs
Medication
Usual Dose
Max Daily Dose (mg)
Common OTC Formulations
Celecoxib*
100-200mg two times per day
400mg
Capsule: 50mg, 100mg, 200mg, 400mg
Ibuprofen
400-800mg three to four times per day
3200mg
Tablet: 200mg, 400mg, 600mg, 800mg
Naproxen
200-400mg two to three times per day
1375-1500mg
Tablet: 220mg, 250smg, 275mg, 375mg, 500mg, 550mg
Capsule: 220mg
Extended release tablet: 375mg, 500mg, 750mg
Ketorolac
10mg four times per day
200mg
Tablet: 10mg
Meloxicam
15mg daily
15mg
Tablet: 7.5mg, 15mg
Capsule: 5mg, 10mg
Safety and Side Effect Considerations
NSAID Risk
Caution
Cardiovascular
Short-term use is safe for most patients.
In patients who have CVD or risk factors for CVD, long-term and high dose NSAID use can increase risk for cardiovascular events (e.g. MI, CVA, CV death).
Avoid use in patients who have undergone CABG surgery.
Gastrointestinal
Short-term use (<=7days) is safe for most patients. Long-term use risk is low (<2%).
In patients >60 years of age, history of peptic ulcers, gastrointestinal bleeds, or Helicobacter pylori infections, consider celecoxib (Celebrex) and/or use of a concomitant proton pump inhibitor (PPI, e.g. OTC omeprazole).
Renal
Acute kidney injury from NSAID use can occur in those with risk factors including patients age >= 65, pre-existing kidney impairment, or CKD with high cumulative doses (e.g. ibuprofen 700 mg/day).
Use with caution in patients with CKD.
Bleeding
Anti-platelet effect is due to COX-1 inhibition, but NSAIDs block COX in a reversible fashion. Normal platelet function returns within 1-3 days depending on the drug (e.g. 1 day for ibuprofen, 2 days for naproxen, diclofenac, and 3 days for piroxicam).
Pregnancy
Avoid use of NSAIDs in pregnancy and consult an obstetric specialist.
Check Medication Monitoring Programs Before you Prescribe.
Prescription drug monitoring programs (PDMPs) are state-level electronic databases that track prescriptions for controlled substances such as opioids11. All 50 states and the District of Columbia have implemented PDMPs in an effort to improve risky opioid prescribing practice and keep patients safe and informed12.
In Michigan, the PDMP is the Michigan Automated Prescription System (MAPS). Michigan law requires that a query of MAPS be performed when an opioid supply of three days or more is prescribed for a patient. It is good practice to check MAPS prior to prescribing any opioid or controlled substance, regardless of duration. See OPEN’s Public Health Policy Initiative for more information.
As prescribers write for fewer opioids, there may be concern about possible increase in phone calls for refills or inadequate pain management. However, OPEN research shows that with appropriate patient education, not only did patients consume less medication, but requests for refills did not increase and patient satisfaction was unchanged. To ensure appropriate pain management, all patients and support person(s) should receive preoperative counseling about postoperative pain and how to manage it.
Set Clear Expectations
Talk about the experience of pain and usual length of recovery with the patient and their support person(s).
“Some pain is normal. You should be able to walk and light activity but may be sore for a few days. This will gradually get better with time.”
“Half of all patients who have this procedure take less than five doses of an opioid medication.”
Discuss Effective Alternatives
Discuss use of the over-the-counter medications.
“Tylenol and Motrin are the first medications we use to manage pain after surgery. By themselves they are often enough to manage your pain.”
“You should take 1000 mg of Tylenol and 600 mg of Motrin together every 6 hours around the clock for the first 3 days after surgery.”
Explain Safer Use
Explain when opioids should be used.
“This opioid medication is only for managing severe pain from your surgery and should not be used to manage pain from any other condition.”
Talk About Risks
Talk about the possible risks associated with opioids.
“We are careful about opioids because they have been shown to be addictive, cause harm, and even cause overdose if used incorrectly or misused.”
Advocate for Disposal
Let patients know that they should dispose of medications after their acute postoperative pain has resolved, and how they should do this.
“Disposing of the opioid medication prevents accidental overdose or misuse. You can use a drug disposal bag, take the pills to an approved collector, often at a police station or pharmacy, or mix the medication with kitty litter in a sealed bag and throw it in your household trash.”
Connect with Primary Care Providers For Better Outcomes
Among surgical patients who develop new persistent opioid use, surgeons provided the majority of opioid prescriptions during the first three months after surgery. By 6 months after surgery, surgeons provided 20% or less of opioid prescriptions, and primary care clinicians increased to over 50% of prescriptions 12 months after surgery13.
While a prescription from a surgeon may be the initial point of opioid exposure for a patient, the relationship a surgeon has with a patient is often episodic and as a result, signs of ongoing use or misuse may not be identified. A primary care provider has a longitudinal relationship with the patient and can be better equipped to identify persistent use, misuse, or onset of substance use disorder. However, primary care providers are often unaware that their patients have received an initial opioid prescription from their surgeon. Providing a primary care provider with information about their patient’s operative procedure and the plan for management of acute postoperative pain (especially if that plan includes an opioid prescription) allows for better communication, consistent messaging, and improved patient monitoring after surgery.
The goal of this communication is to let the primary care provider know that their patient had surgery, when it occurred, the plan for pain management, whether an opioid was prescribed and, if so, how much was dispensed, and the expectations in terms of pain duration and plan for refills (if any).
Ideas in terms of sharing this information include using the capability of the electronic medical record to auto-populate a letter or communication to the primary care provider containing this information. If an after-visit summary is created by your electronic medical record, you might forward a copy of this automatically to the primary care provider. Providers could also add standard language to their operative notes containing this information and forward the operating report to the primary care provider.
Hill, M. V., McMahon, M. L., Stucke, R. S., & Barth, R. J. (2017). Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Annals of Surgery, 265(4), 709–714. https://doi.org/10.1097/sla.0000000000001993
Bicket, M. C., Long, J. J., Pronovost, P. J., Alexander, G. C., & Wu, C. L. (2017). Prescription opioid analgesics commonly unused after surgery. JAMA Surgery, 152(11), 1066. https://doi.org/10.1001/jamasurg.2017.0831
Howard, R., Waljee, J., Brummett, C., Englesbe, M., & Lee, J. (2018). Reduction in opioid prescribing through evidence-based prescribing guidelines. JAMA Surgery, 153(3), 285. https://doi.org/10.1001/jamasurg.2017.4436
Waljee, J. F., Li, L., Brummett, C. M., & Englesbe, M. J. (2017). Iatrogenic opioid dependence in the United States. Annals of Surgery, 265(4), 728–730. https://doi.org/10.1097/sla.0000000000001904
Lee, J. S., Hu, H. M., Brummett, C. M., Syrjamaki, J. D., Dupree, J. M., Englesbe, M. J., & Waljee, J. F. (2017). Postoperative opioid prescribing and the pain scores on hospital consumer assessment of Healthcare Providers and Systems survey. JAMA, 317(19), 2013. https://doi.org/10.1001/jama.2017.2827
Howard, R., Fry, B., Gunaseelan, V., Lee, J., Waljee, J., Brummett, C., Campbell, D., Seese, E., Englesbe, M., & Vu, J. (2019). Association of Opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surgery, 154(1). https://doi.org/10.1001/jamasurg.2018.4234
Sekhri, S., Arora, N. S., Cottrell, H., Baerg, T., Duncan, A., Hu, H. M., Englesbe, M. J., Brummett, C., & Waljee, J. F. (2018). Probability of opioid prescription refilling after surgery. Annals of Surgery, 268(2), 271–276. https://doi.org/10.1097/sla.0000000000002308
Lee, J. S.-J., Hu, H. M., Edelman, A. L., Brummett, C. M., Englesbe, M. J., Waljee, J. F., Smerage, J. B., Griggs, J. J., Nathan, H., Jeruss, J. S., & Dossett, L. A. (2017). New persistent opioid use among patients with cancer after curative-intent surgery. Journal of Clinical Oncology, 35(36), 4042–4049. https://doi.org/10.1200/jco.2017.74.1363
Goesling, J., Moser, S. E., Zaidi, B., Hassett, A. L., Hilliard, P., Hallstrom, B., Clauw, D. J., & Brummett, C. M. (2016). Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain, 157(6), 1259–1265. https://doi.org/10.1097/j.pain.0000000000000516
Brummett, C. M., Waljee, J. F., Goesling, J., Moser, S., Lin, P., Englesbe, M. J., Bohnert, A. S., Kheterpal, S., & Nallamothu, B. K. (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery, 152(6). https://doi.org/10.1001/jamasurg.2017.0504
Ball, S. J., Simpson, K., Zhang, J., Marsden, J., Heidari, K., Moran, W. P., Mauldin, P. D., & McCauley, J. L. (2020). High-risk opioid prescribing trends: prescription drug monitoring program data from 2010 to 2018. Journal of Public Health Management and Practice, Publish Ahead of Print. https://doi.org/10.1097/phh.0000000000001203
Klueh, M. P., Hu, H. M., Howard, R. A., Vu, J. V., Harbaugh, C. M., Lagisetty, P. A., Brummett, C. M., Englesbe, M. J., Waljee, J. F., & Lee, J. S. (2018). Transitions of care for postoperative opioid prescribing in previously opioid-naïve patients in the USA: A retrospective review. Journal of General Internal Medicine, 33(10), 1685–1691. https://doi.org/10.1007/s11606-018-4463-1
