Prescription of Pain Medication at Discharge after Elective Surgery

1. Patient education
    1. Patients and their families and/or care-givers should be provided with written and verbal information on their pain management options preoperatively including:

      ● Expectations regarding functional recovery (returning to meaningful physical activities)

      ● Realistic pain management goals (goal is function, not zero pain)

      ● Multimodal pain management options (e.g. opioid options, non-opioid options and non-pharmacological options)

      ● Possible interaction of patient’s current medications and their potential interactions with opioids (e.g. sleeping pills; alcohol; benzodiazepines)

      ● Risk of potential opioid side effects, overdose, and development of a dependence or addiction

      ● Safe opioid use and discontinuation

      ● Risk factors for opioid use disorder (history of substance use disorder; depression; anxiety)

      1. This information should be reinforced and reviewed prior to discharge .
    2. Patients should be provided with written and/or verbal information prior to discharge on the safe storage and disposal of unused opioids in accordance with Health Canada’s recommendations.
      1. Store opioids in a secure place to prevent theft or accidental exposure
      2. Keep opioids out of sight and reach of children and pets
      3. Do not keep opioid medications for when they “might” be needed
      4. Do not throw opioids into household trash where children and pets may find them
      5. Do not flush opioids down the toilet
      6. Return expired, unused or used opioids to a pharmacy for proper disposal
2. Risk factors for persistent postoperative opioid use
    1. Preoperatively, patients should be assessed for the following risk factors as they may be at increased risk for persistent postoperative opioid use:

      ●Surgical procedures associated with significant nerve damage that may put patients at risk to develop neuropathic pain

      ●History of or concurrent anxiety and/or depression and/or high levels of pain catastrophizing and/or PTSD

      ●Use of medications for depression and/or anxiety (e.g. benzodiazepines and selective serotonin reuptake inhibitors)

      ●Currently or previously followed and treated for chronic pain under medical supervision

      ●History of drug use, smoking and/or alcohol use disorder (previously or currently)

      ●Low socioeconomic status

      ●Aged 18-30 years old

      1. If a patient is at perceived risk for persistent opioid use, a tailored opioid-sparing perioperative pain management plan should be developed by the perioperative team (including surgeons, anesthesiologists, and/or the pain team) preoperatively
3. Discharge prescriptions for pain management after elective surgery
    1. Non-opioid therapy should be the first line of treatment for pain. Therapies can be pharmacological (e.g. NSAIDS, acetaminophen, or regional anesthetic techniques) or non-pharmacological (e.g. physical therapy, ice/heat, elevation, breathing exercises, meditation etc.)
    2. Patients should be discharged with a prescription for the following adjunct pain medications unless contraindicated:

      ●Acetaminophen 1 g PO TID to QID for 7 days then PRN AND

      ●NSAIDS (e.g. naproxen 500 mg BID or ibuprofen 400 mg QID) PO for 3 days then PRN

      1. Patients should be counselled on how to take scheduled medications and advised to stop taking these medications after 7 days if they are expected to have a rapid recovery; 14 days if they are expected to have a moderate or long-term recovery
    3. Patients should receive a prescription for opioid-containing tablets based on their consumption in hospital during the previous 24 hours.
      1. Patients should receive the same opioid analgesic that they received in hospital to ensure tolerability
      2. Patients who did not receive opioids in the last 24 hours of their hospital stay should not be given a prescription for opioids
      3. Day surgery patients should be prescribed medications according to expected rapid recovery in Table 1
    4. Prescriptions for opioid-containing tablets should be written during the discharge process. Prescriptions should not be written in advance (i.e. prior to surgery) for surgical inpatients.
    5. Patients who are given a prescription for opioid-containing tablets should be instructed to fill the prescription only if their pain is not well managed with other therapies or if they are having difficulty completing activities of daily living secondary to pain.
    6. Opioid prescribing should be based on expected functional recovery (provided the patient has not exceeded this dose in the past 24 hours)
      1. Patients with an expected rapid recovery (resume regular activities within two weeks from discharge) should be prescribed enough opioid containing tablets for 0-3 days following discharge (maximum 12 opioid-containing tablets)
      2. Patients with an expected moderate recovery (resume regular activities within 4 weeks from discharge) should be prescribed opioid-containing tablets for a maximum of 7 days following discharge (maximum 30 opioid-containing tablets)
      3. Patients with an expected long-term recovery (resume regular activities longer than 4 weeks from discharge) should be prescribed opioid-containing tablets for a maximum of 14 days following discharge (maximum 60 opioid containing tablets)
  1. A part fill or second prescription should be given to patients with an expected moderate or long term recovery to reduce the number of opioid-containing tablets distributed at one time. (see appendix 1 for an example of a part fill prescription)
  2. The prescription for opioid-containing tablets should have an expiry date of 30 days from the date of discharge.
  3. If opioid-containing tablets are prescribed, they should be short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration. Patients should be prescribed one of the following opioid-containing tablets:

    ●Morphine 5 mg, PO q4h PRN for 3 days then q8h PRN

    ●Hydromorphone 1 mg, PO q4h PRN for 3 days then q8h PRN

    ●Tramadol^ 50 mg, PO q4h PRN for 3 days then q8h PRN

    ●Oxycodone^ 5 mg, PO q4h PRN for 3 days then q8h PRN

4. Follow-up and long-term opioid use
    1. Surgeons should ask their patients at follow-up about their postoperative pain and opioid use. Patients should be instructed to return unused opioids to their local pharmacy at the time of their follow-up if they are not being used.
    2. If patients require a refill prior to their scheduled follow-up visit, a prescription for a maximum of 14 days (maximum 60 opioid-containing tablets) should be prescribed. Dated part fills for 7-day intervals should be given.
    3. If pain persists beyond 3 months, patients should be referred to a transitional/chronic pain clinic.
    4. If there is a suspicion that a patient is misusing opioids, the patient should be referred to a transitional/chronic pain clinic.