patients should be counseled on how and when to take
For patients who need to use opioid medications
for more than two weeks, a tapering plan should be
implemented, decreasing the discharge dose by 20 to
25 percent every one to two days to abate symptoms
of severe withdrawal.
14 Counseling patients on how
to take pain medications (for example, with or without food) and how to manage the side effects should
be included in the discharge instructions. During the
postoperative visit, patients should also be warned to
avoid alcohol and other central nervous system depressants to avoid accidental overdose.
If surgeons are committed to ending the opioid
epidemic, we must not only decrease the number of
opioid medications prescribed, but also educate our
patients to properly and safely dispose of excess opioid
medications. More than 70 percent of pills prescribed
to general surgery patients in the acute postoperative
period go unused, but only 9 percent of patients dispose
of their medications according to U. S. Food and Drug
Administration (FDA) guidelines.
11 The FDA recommends disposing of opioid pills at Drug Enforcement
Administration-approved collection sites, community-based drug “take-back” programs, flushing them down
the toilet, placing them in a sealable plastic bag, or
dissolving the pills in water and mixing them with
compostable materials (such as coffee grounds) and
placing the mixture in a sealable bag before placing in
15 Surgeons should provide patients with written instructions on proper disposal guidelines prior to
discharge, for their reference at home.
These same recommendations for opioid education
apply to patients who receive care from subspecialty
surgeons. However, the unique circumstances of acute,
postoperative pain in children, oncology patients,
and patients with inflammatory bowel disease (IBD)
warrant special consideration. In some instances, the
patient’s preoperative anxiety may preclude proper
attention to opioid counseling. Providers should tailor
the timing of their approach to best fit each patient’s
needs. It is important to include the individuals who
will assist in caring for the patient upon discharge in
any counseling session with the patient.
Patient education should apply a multidisciplinary
approach, and the surgeon should not underestimate
the effect of other team members in counseling the
patient on pain management. For example, the nurse
or team pharmacist responsible for the last interaction
with the patient prior to discharge has an opportunity
to expand the patient’s knowledge and understanding
of appropriate opioid use, weaning, storage, and disposal. It is crucial to remind all members of the health
care team that their interactions and time with patients
make a difference.
While the number of overall opioid prescriptions written for children is relatively low, rates have nearly
doubled in the last decade.17 Galinkin and colleagues
suggest that dependence, but not necessarily addiction,
can occur in children after just one week of opioid use.
After discharge, the parents or guardians are responsible for dosing and administration of pain medication to
children, and it is imperative that health care providers
educate parents regarding the balance between pain
control and overuse. As with other surgical settings,
when possible, this counseling should begin preoperatively and include a multidisciplinary approach.
The safe storage and disposal of opioids is a crucial
aspect of patient education, especially in settings where
children may access them. With one-fifth of unintentional opioid overdoses in children younger than six
years old occurring due to the ingestion of a medication that was prescribed for an adult, proper guardian
education about the storage and disposal of opioids is
19 While these conversations are critical in
the pediatric surgery setting, they are equally as important to have with any patient who will be prescribed
opioids and resides with young children.
Special consideration should be given to adolescent
patients, especially those who may be directly managing their own medication administration. Studies
AUG 2017 BULLETIN American College of Surgeons
THE OPIOID EPIDEMIC