Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Abstract

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

Keywords: multimodal analgesia; opioid stewardship; opioid-related adverse effects; pain management; perioperative care; perioperative medication management; postoperative pain; preemptive analgesia; regional anesthesia; transitions of care.

Figure 1

Perioperative Pain Management and Opioid Stewardship Interventions across the Continuum of Care. Legend: DOS = day of surgery, IV = intravenous, MAT = medication-assisted treatment (i.e., for substance use disorders), O-NET+ = opioid-naïve, -exposed or -tolerant, plus modifiers classification system, ORAE = opioid-related adverse event, PCA = patient-controlled (intravenous) analgesia, PDMP = prescription drug monitoring program.

Figure 2

Example of a Pain Management Exit Plan (PMEP) to be used at postoperative hospital Discharge.