Surgical unit strategies to mitigate postoperative opioid dependence
| Preoperative screening | Identification of patients at risk of developing CPSP.
Identification of patients developing opioid substance use disorder. Identification of patients on pre-existing opioids. |
| Preoperative interventions | Preoperative opioid weaning.
Individual counselling and creation of realistic expectations concerning the risk and benefits of surgery. Discussion about the need for post-discharge opioid weaning. |
| Operative interventions | Administration of both paracetamol and NSAIDs where safe.
Procedure specific analgesic strategies ie appropriate regional analgesic techniques that promote return of function. Low-dose ketamine. Other atypical analgesics eg lidocaine, magnesium and the gabapentinoids. Opioid ‘light’ anaesthesia and avoidance of remifentanil. |
| Postoperative interventions | Use of functional pain scores to guide subsequent analgesia administration.
Use of numerical pain scores to identify patients at risk of developing CPSP or a surgical catastrophe. Use of sedation scores to identify patients at risk of OIVI. Reduced reliance on WHO analgesic ladder. Avoidance of compound analgesics. Avoidance of modified release opioid preparations. Avoidance of more addictive opioids. |
| Preparation for discharge interventions | Avoidance of compound analgesics.
Avoidance of modified release opioid preparations. Avoidance of more addictive opioids. Limit duration of opioid prescription. Regular simple analgesics. |
| Patient discharge education | Promote opioid weaning.
Set realistic expectations regarding analgesia. Promote regular administration of simple analgesics. Promote use of non-pharmacological analgesic strategies. Avoid repeat opioid prescriptions. Promote safe opioid disposal. Avoid opioid diversion. |
CPSP = chronic post-surgical pain; NSAIDs = non-steroidal anti-inflammatory drugs; OIVI = opioid-induced ventilatory impairment; WHO = World Health Organization.