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Planning for the Alleviation of Pain After Surgery

Planning and preparing people for discomfort after a surgical procedure is itself an important way to alleviate pain. 

The current “opioid crisis” in the United States and Canada can be traced to promotion of opioids as the primary treatment for pain. These two countries make up 5% of the global population but consume 90% of the world’s opioids.

Preparing People for Discomfort

Patients may place a great deal of hope on surgery and are already suffering from pain.  They may have placed so much trust and confidence in us that they don’t prepare adequately or they have unrealistic expectations for the recovery process.  Planning recovery demonstrates compassion.  It is an opportunity to remind patients that they will need to take an active role in their recovery, including safe and effective alleviation of pain. The decision to schedule surgery should be followed by a discussion about recovery.

  • Demonstrate care and compassion. Prepare patients for the recovery process. 
    • “We want you to be as comfortable as possible after your surgery.”
    • “Pain is a part of the healing process.”
    • “Your body will need time to heal.”
  • Let patients know you will support them – reinforce your partnership during recovery.
    • “If it feels like something is wrong, you can always check with us.”

Make a Plan

Planning demonstrates care and can reduce stress.

  • Plan for safe and effective alleviation of pain
    • “What did you do for the pain after your last surgery?”

Most patients will say, “I took a few opioids and then switched to Tylenol or Motrin”-- a strategy that can be reinforced.  Patients who have struggled to get comfortable may benefit from screening for stress, distress, and less effective coping strategies. Surgery can be postponed to address any matters identified. When surgery can’t be delayed, be prepared to get help for the patient, including social work, psychology, addiction, or psychiatry consultations.  And prepare yourself for important conversations with the patient during recovery.

  • Consider routine screening for symptoms of depression, less effective coping strategies, and propensity for opioid misuse (use opioid risk assessment tools)
  • Plan for safe and effective alleviation of pain
    • Assess readiness.
    • Gauge peace of mind. Optimize mood and coping strategies.
    • Check on social support.
    • Provide tips, such as distraction, getting into one’s routine, social support, laughter, and physical activity.
    • Recommend non-opioid analgesics: NSAIDs and Worry less about using NSAIDs than opioids. A recent review shows no clear effect of NSAIDs on bone healing.1
    • Consider the appropriate use of local and regional anesthetics.
    • Consider alternatives that might appeal to some patients: meditation, guided imagery, aromatherapy, massage, medical hypnosis, acupuncture, transcutaneous electrical nerve stimulation (TENS), continuous passive motion, or listening to music.
    • Build resilience and address depression and anxiety prior to scheduling elective surgery.
    • If opioids are used, prescribe the smallest dose for the shortest time possible. Note maximums for strength, number of pills, and duration. See Orthopaedic Department Opioid Safety Strategy here. Emphasize opioids for the first 24-48 hours, perhaps mostly for sleep, and then rapid transition to non-opioid pain relievers.
    • Consider adding a pain management physician consultation in more complex cases with the creation of a specific plan.
    • Do not prescribe patients who do not want to take opioids after surgery for the reason of “just in case”.
  • Discuss the safe storage and disposal of opioids
  • For patients on daily opioids or medication-assisted treatment for opioid use disorder (methadone or suboxone), coordinate care with the primary care physician and the opioid prescriber.

Consider written or internet-based material documenting the plan for safe and effective alleviation of pain for patients and their family members to review and ask questions prior to surgery. You can use this template to get started.

1. Marquez-Lara A, et al. Nonsteroidal anti-inflammatory drugs and bone-healing: a systematic review of research quality. JBJS Rev. 2016;4(3).