Opioids for Surgical Procedures Clinical Practice Guidelines (2018)

Opioids After Surgery Workgroup

Reviewed and summarized by Medscape editors

November 02, 2018

The guidelines on prescribing opioids following surgical procedures were released on October 1, 2018, by the Opioids After Surgery Workgroup.[1]

The Opioids After Surgery Workgroup has developed guidelines concerning prescription of opioid medications following 20 commonly performed surgical procedures in adult patients who are opioid-naive, do not have chronic pain, and do not have surgical complications. The 20 procedures included in these guidelines were chosen because of their frequent performance and minimal surgical variation. The guidelines define an opioid tablet as an oxycodone 5 mg oral equivalent.

The panel recommended 0 as the minimum number of opioid tablets prescribed for all procedures listed in the guidelines. They recommended ibuprofen for all patients without contraindications.

The panel established 5 important qualifying factors to consider during the process of prescribing opioid medications, as follows:

  1. The patient's wishes and history of medication effectiveness (ie, in the past and during hospital stay) should be considered when prescribing any pain medication. Patients who overtly state a desire to avoid opioids should not be prescribed opioids. In addition, opioids should not be prescribed if the patient’s postsurgical pain is adequately managed with nonsteroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen alone before discharge.

  2. Patients should be advised to maximize pain relief with nonopioids (acetaminophen, NSAIDs) before using opioid medications.

  3. Patients should be fully informed concerning the risks and benefits of opioids and be made aware that fatal addiction is a potential risk.

  4. Patients with terminal conditions should be considered special cases, since palliation may be an indication.

  5. The patient's potential medical contraindications, body weight, response to multimodal pain therapy, potential for addiction, and risk aversion should be considered before opioids are prescribed.

When postoperative opioids are not prescribed, patients should receive specific administration instructions for commonly available OTC nonopioid pain medications and receive instructions on how to seek help if the pain becomes debilitating using OTC analgesics alone. Patients should also receive discharge instructions (ie, medications, doses, frequency) to optimize scheduled nonopioid medications, unless medically contraindicated.

The maximum number of opioid tablets to prescribe postoperatively depends on the procedure but should not exceed 20. The minimum (0 in all cases) and maximum (if any) opioid tablets per selected procedure are listed below.

General Surgery

  • Laparoscopic cholecystectomy: 0-10 opioid tablets

  • Laparoscopic inguinal hernia repair, unilateral: 0-15 opioid tablets

  • Open inguinal hernia repair, unilateral: 0-10 opioid tablets

  • Open umbilical hernia repair: 0-15 opioid tablets

Breast Surgery

  • Partial mastectomy without sentinel lymph node biopsy: 0-10 opioid tablets

  • Partial mastectomy with sentinel lymph node biopsy: 0-15 opioid tablets

Thoracic Surgery

  • Video-assisted thoracoscopic wedge resection: 0-20 opioid tablets

Orthopedic Surgery

  • Arthroscopic partial meniscectomy: 0-10 opioid tablets

  • Arthroscopic anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL) repair: 0-20 opioid tablets

  • Arthroscopic rotator cuff repair: 0-20 opioid tablets

  • Open reduction and internal fixation (ORIF) of the ankle: 0-20 opioid tablets

Gynecologic Surgery and Obstetric Delivery

  • Open hysterectomy: 0-20 opioid tablets

  • Minimally invasive hysterectomy: 0-10 opioid tablets

  • Uncomplicated cesarean delivery: 0-10 opioid tablets

  • Uncomplicated vaginal delivery: 0 opioid tablets

Urologic Surgery

  • Robotic retropubic prostatectomy: 0-10 opioid tablets

Otolaryngology

  • Thyroidectomy, partial or total: 0-15 opioid tablets

  • Cochlear implant: 0 opioid tablets

Cardiac Surgery

  • Coronary artery bypass grafting: 0-20 opioid tablets

  • Cardiac catheterization: 0 opioid tablets

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