Prescription and management of opioids after surgery

1. Opioid-containing tablets to be prescribed at discharge
    1. For patients who are discharged on the day of surgery or post-operative day 1, patients should be prescribed no more than 10-15 opioid containing tablets (John Hopkins)
    2. For patients who are discharge on postoperative day 2+, the number of opioids prescribed should be based on the number of opioid-containing tablets/medications that were prescribed in hospital (Hill et al, 2017)
      1. Patients who took no pills are not prescribed any
      2. Patients who took 1-3 pills are prescribed 15 pills
      3. Patients who took 4 or more pills are prescribed 30
    3. Patients should be prescribed one of the following opioid-containing tablets (John Hopkins)
      1. Oxycodone 5 mg, q6-8hrs, PRN for 2 days, OR;
      2. Dilaudid 1-2mg, q6-8hrs, PRN for 2 days, OR;
      3. Morphine 5mg, q6-8hrs, PRN for 2 days,
    4. In addition to or in the absence of opioid-containing tablets, patients should be discharged with the following adjunct pain medications (John Hopkins)
      1. Acetaminiphen 1g PO q8hrs for first week/ 1g PO Q12hrs for second week/ 1g PO q8hrs after 2nd week
      2. Ibuprphen (NSAIDS) 400 mg q8 hrs for 3 days followed by 200 mg q8hrs prn for pain OR;
      3. Celecoxib (NSAIDS – cox -2) 200mg q12 hrs for 3 days
      5. *If normal renal function
2. Risk factors for chronic opioid perioperatively
    1. Preoperatively, the following patients may be at increased risk for postoperative opioid misuse

      ● Surgical procedures associated with significant nerve damage have shown significant associations with the development of neuropathic pain & persistent opioid use. (i.e. Thoracic surgery, Mastectomy with axillary dissection, Amputations)

      ● Patients presenting for surgery with a history of or concurrent anxiety and / or depression and / or high levels of pain catastrophizing

      ● Patients presenting for surgery with a chronic pain diagnosis

      ● Preoperative history of drug and / or alcohol abuse

      ● Male patients

      ● Patients with low socioeconomic status

      ● Younger patients (age range?)

      ● Patients using benzodiazepines and selective serotonin reuptake inhibitors presenting for surgery

    2. Postoperatively, patients undergoing procedures that have linked with a higher risk of opioid abuse/overuse (e.g. thoracic procedures, surgeries with risk of trauma or nerve damage, joint replacements) are at higher risk. Consider involvement of a specialized pain service in this cohort of patients.
3. Safe disposal of opioids
    1. When prescribing medications encourage patients to store opioid medications safely out of the reach of children and preferably in a locked location.
    2. Speak to patients about the proper disposal of unused opioid medications.
    3. Unused medications can be returned to pharmacies or can be safely disposed of by:
      1. Removing the medications from their original containers. Scratching out all identifying information on the prescription label to help protect patient’s identity and the privacy of their personal health information.
      2. Mix the medications in something unappealing, such as used coffee grounds or kitty litter. This makes the drug less attractive to children and pets, and unrecognizable to people who go through the trash seeking drugs.
      3. Place this mixture in a closed bag, empty can or other sealed container to prevent the drug from leaking or breaking out of a garbage bag.