Archive September 2018 XIX, No. 9

Safety: How Many Pain Pills Do Patients Really Need?

Match the number of opioids to the procedure to stop overprescribing.

Michael Englesbe

Michael Englesbe, MD, FACS

BIO

CLINICAL UTILITY
ON HAND Research has shown that patients will take the number of pills they're prescribed.

An abdominal hysterectomy is a lot more painful procedure than a thyroidectomy, so why write for the same number of opioids for each patient? To control the hysterectomy patient's post-op pain, 35 Vicodin or 25 Percocet seems appropriate. The thyroidectomy patient will only need 10 Vicodin or 5 Percocet. We know, however, that many surgeons routinely prescribe more pain pills than patients will need, either out of habit or out of fear that they'll get more phone calls for refills or inadequate pain control if they write for fewer opioids.

You can help your surgeons rethink their prescribing practices. As part of the Opioid Prescribing Engagement Network (OPEN), a group working to prevent the overprescribing of opioids, I helped develop the opioid prescribing recommendations we listed for you on the opposite page. The recommendations are meant to ensure patients receive the right amount of pills to manage the pain they're likely to experience after several common procedures. We'll soon add recommendations for hip and knee replacement patients (opioidprescribing.info).

Right-sizing opioid use not only limits opioid-related post-op complications such as nausea and intestinal issues that can lead to readmissions, but also helps curb the opioid epidemic. As we know, surgeons introduce many patients to opioids and prescribe the vast majority of unused opioids.

Counseling patients

Prescribing recommendations provide a framework for how many pills patients should receive after surgery, but efforts to right-size post-op opioid use should also include communicating with patients.

  • Set realistic expectations. Surgery will hurt. Patients need to understand that eliminating post-op pain entirely is both unrealistic and inappropriate. Tell them that some pain is normal, but they should be able to walk and perform light activities during the first few days of recovery. Let them know that their pain will gradually dissipate.
  • Share norms. Inform patients that the recommended pill amounts are based on scores of patient-reported data and that many patients claim they need only up to 5 pills to adequately manage their pain.
  • Tout non-opioid options. Advise patients to take acetaminophen and ibuprofen around the clock, and use opioids only as needed to treat breakthrough pain. One important note: Avoid the use of NSAIDs in patients with peptic ulcer disease and associated risk factors such as smoking, drinking, bleeding disorders and renal disease.
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