Managing Postoperative Pain

1. What procedure was performed and what is the expected pain severity? Default: [VERIFY — obtain from operative report]
2. Does the patient have chronic pain or current opioid use? Default: no opioid use
3. What is the patient's renal function (GFR) and hepatic function? Default: normal
4. Does the patient have a history of substance use disorder? Default: no
5. Were any regional anesthetic techniques used (nerve block, epidural, TAP block, local infiltration)? Default: none
6. Does the patient have allergies or intolerances to specific analgesics? Default: NKDA
7. Is the patient enrolled in an ERAS pathway? Default: no
8. What is the patient's weight (for dose calculations)? Default: [VERIFY]

Documents to Request

• Operative report (procedure details, EBL, regional anesthesia used)
• Anesthesia record (intraoperative opioid doses, regional techniques)
• Preoperative pain assessment and opioid use history
• State PDMP (Prescription Drug Monitoring Program) report
• Allergy list
• Pharmacy medication reconciliation
• Institutional opioid stewardship protocol

Step 1: Pain Assessment Framework

Perform structured pain assessments at standardized intervals:

Assessment tools:

Assessment frequency:

• PACU: Every 15 minutes until discharge criteria met
• Floor (POD 0-1): Every 4 hours and 30 minutes after each intervention
• Floor (POD 2+): Every 8 hours with each nursing assessment

Functional pain goals (document these, not just a NRS number):

• Can the patient take a deep breath and use incentive spirometry? (NRS ≤4 target)
• Can the patient get out of bed and ambulate? (NRS ≤4 target)
• Can the patient sleep without being awakened by pain? (NRS ≤3 target)

Step 2: Multimodal Analgesia Protocol

Layer non-opioid analgesics as the foundation, adding opioids only for breakthrough pain:

Tier 1 — Scheduled Non-Opioid Foundation

Tier 2 — Adjunctive Agents

Tier 3 — Regional Anesthesia Techniques

Step 3: Opioid Prescribing with Stewardship

When opioids are required for breakthrough pain (NRS ≥4 despite multimodal regimen):

Inpatient opioid orders:

Opioid stewardship documentation requirements:

• Calculate daily oral morphine equivalents (OME) and document in the chart
• Target: de-escalate to PO-only opioids by POD 2
• Target: reduce OME by ≥25% daily from peak consumption
• If OME >90 mg/day for >48h, trigger pharmacy and pain service review
• Document PDMP check prior to discharge opioid prescriptions

Opioid-tolerant patients (defined as ≥60 mg OME/day for ≥1 week):

• Continue baseline opioid regimen (do not withdraw)
• Add non-opioid multimodal agents aggressively
• Consider ketamine infusion for opioid-sparing effect
• Consult Acute Pain Service
• Set realistic functional goals (may not achieve NRS 0)

Step 4: Monitoring and Safety

Opioid-related adverse effect monitoring:

Naloxone (Narcan) protocol:

• For respiratory depression (RR <8 or unresponsive): Naloxone 0.04-0.4 mg IV, repeat Q2-3 min
• For over-sedation without respiratory failure: Start with 0.04 mg IV (low dose to avoid precipitating withdrawal in opioid-tolerant patients)
• Have naloxone available at the bedside for all PCA patients

Step 5: Discharge Pain Management and Opioid Prescribing

Discharge prescribing framework:

Mandatory discharge documentation:

• Non-opioid medications to continue (acetaminophen, ibuprofen scheduled)
• Opioid prescribed: name, dose, quantity, refill policy (no refills for acute surgical pain)
• PDMP checked and documented
• Patient education: opioid storage, disposal (drug take-back), overdose signs
• Expected pain trajectory: "Pain should improve daily; if worsening after POD 3-5, contact our office"
• Follow-up appointment with timeline for reassessment

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the multimodal regimen documented with scheduled non-opioid foundation before any opioid orders?
2. Are opioids ordered as PRN only (no scheduled opioids unless chronic pre-existing use)?
3. Is the daily OME being tracked and a de-escalation target set?
4. Are monitoring parameters (respiratory rate, sedation scale, SpO2) ordered with action thresholds?
5. Is the discharge opioid prescription within the institutional quantity limit with PDMP documentation?

Quality Audit

• Pain assessment tool documented (NRS, CPOT, BPS)
• Functional pain goals documented (spirometry, ambulation, sleep)
• Multimodal non-opioid regimen ordered as scheduled (not PRN)
• Regional anesthesia technique documented (if used)
• Opioid orders include dose, route, frequency, and indication (NRS threshold)
• Daily OME calculated and documented
• OME de-escalation trajectory documented
• Opioid-tolerant status identified and baseline regimen continued
• Respiratory monitoring ordered with specific RR and sedation thresholds
• Naloxone availability verified for PCA patients
• PDMP checked before discharge opioid prescribing
• Discharge opioid quantity within institutional guidelines
• Patient education on opioid safety, storage, and disposal documented
• Follow-up plan includes pain reassessment timeline

Guidelines

1. Non-opioid multimodal agents are the FOUNDATION, not the adjunct — start acetaminophen and NSAIDs scheduled before the patient awakens, and add opioids only for breakthrough.
2. Never order a basal rate on a PCA for opioid-naive patients — this is the leading modifiable risk factor for PCA-related respiratory depression.
3. Track and document daily OME — this is the single most important metric for opioid stewardship and identifies patients at risk for persistent opioid use.
4. Check the state PDMP before every discharge opioid prescription. Document the check.
5. For patients with substance use disorder, involve the Acute Pain Service and addiction medicine (if available) early — do not withhold appropriate analgesia, but implement enhanced monitoring and a structured taper.
6. Gabapentin/pregabalin are effective adjuncts for surgical pain but carry sedation risk, especially combined with opioids in elderly patients — start at the lowest dose and titrate.
7. Set functional pain goals (spirometry, ambulation, sleep) rather than targeting a specific NRS number — an NRS of 4 with full functional recovery is better than an NRS of 0 with oversedation.
8. Educate patients that postoperative pain is expected to improve daily; worsening pain after POD 3-5 should prompt clinical reassessment for complications, not just escalating analgesics.