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Hance Clarke
Dr. Hance Clarke, Director of Pain Services at Toronto General Hospital, led the team of healthcare professionals and patient partners who developed the new plan. (Photo: Courtesy Hance Clarke)

Pain following surgery is one of the greatest worries when someone needs to have an operation.

Until recently, ensuring zero pain post surgery has been the gold standard of care, and prescribing opioids was an effective answer for most patients. But with thousands of deaths worldwide due to opioid overdoses, all aspects of pain management and opioid prescribing is under a microscope.

"Some patients may not be well prepared for the potential pain consequences and are psychologically vulnerable going into surgery," says Dr. Hance Clarke, Director of Pain Services at Toronto General Hospital. "Without supports it can cause some to head down a path that leads to poor outcomes and a diagnosed opioid use disorder."

It might be surprising to some that in the midst of the ongoing opioid crisis, there doesn't currently exist a standardized set of guidelines for pain management. A team of healthcare professionals (Best Practices in Surgery at the University of Toronto) and patient partners led by Dr. Clarke have addressed this problem with Canada's first "Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery," published today in The Canadian Journal of Pain. Read more about the statement.

"We have always had practices," says Dr. Clarke. "But these practices were largely handed down from generation to generation without much evidence to support it. We are reframing the perioperative prescribing landscape by basing it on evidence and expert opinion."

Unlike in Scandinavia, in North America 70 per cent of patients leave the hospital with an opioid containing medication. This new suggested guideline offers four recommendations to tackle that staggering number and give patients the best possible chance to recover, without a meaningful risk of addiction.

Recommendations

  1. Patient Education: patients and their families need written and verbal information on their pain management options with an emphasis on realistic goals of return to function, not zero pain.
  2. Risk factors for persistent postoperative opioid use: patients should be assessed for risk factors including (but not only) type of surgical procedure, history of anxiety and/or depression and age and socioeconomic status.
  3. Discharge prescriptions for pain management after elective surgery: non-opioid therapy such as NSAIDS should be the first line of treatment.
  4. Follow up and long-term opioid use: Surgeons should ask patients at their follow up about their pain management and opioid use. If pain persists past three months, patients should be referred to a transitional/chronic pain clinic.

Long established practices have allowed a glut of unused opioid medications. This leads to copious amounts being available for diversion.

This proactive, patient-facing approach will reduce opioid diversion and maintain patient pain needs for those who have never been on an opioid and often do not need the amount of opioid medications prescribed at discharge.

Given the evolving landscape of pain medicine due to the opioid crisis, recommendations from the perioperative world such as the ones published today will keep patients' pain needs front and centre while leading to a safer context for all of society.  


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