Surgery Pain Management

OPEN strives to give patients the tools they need for pain management. Learn about preparing for surgery, talking with your surgeon, strategies to manage pain such as over-the-counter medications, non-medication options, and opioid medications.

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.

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

*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.

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.

Tips for Reducing Opioid Risk

• 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.
• Practice safe opioid storage and disposal. Learn more with OPEN’s Safe Storage and Disposal Initiative.

Healthcare providers can find current evidence to support appropriate opioid prescribing, best practices for pain management, opioid prescribing recommendations which can be tailored to meet patient needs, counseling suggestions to educate patients on postoperative expectations, and care coordination strategies to manage complex care needs.

EVIDENCE SHOWS:

Greater than 70% of prescribed opioids are not used ^1,2

Reducing opioid prescribing improves the safety for patients, families, and communities 

• Postoperative opioid prescribing varies significantly¹  
• 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 use^8,9,10

New persistent opioid use is one of the most common surgical complications

• Many patients continue to use their opioids for reasons other than surgical pain^9,10
• New persistent opioid use after surgery is an underappreciated surgical complication that warrants increased attention^8,9,10

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

• 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

Safety and Side Effect Considerations

See OPEN’s Prescribing Recommendations Initiative for more information.

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.

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.

1. 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 
2. 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 
3. 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 
4. 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 
5. 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 
6. 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 
7. 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 
8. 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 
9. 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 
10. 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 
11. Substance Abuse and Mental Health Services Administration. (2017). In brief, Prescription Drug Monitoring Programs: A guide for healthcare … Retrieved May 2, 2023, from https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4997.pdf 
12. 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
13. 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