procedure-specific recommendations enabled surgeons to reduce
the number of narcotic pills that they prescribe by more than 50
percent; patients who received opioids were adequately managed by the initial prescriptions in 80 percent of the 246 cases
6 Unfortunately, formal curricula for pain assessment
and management in postoperative patients is lacking in both
breadth and standardization. Though some courses have demonstrated improvements in analgesic prescribing patterns after
implementation of a mandatory palliative care curriculum for
residents, no nationally recognized or mandated pain management courses are available to surgical residency programs.
16 - 17
Furthermore, residents receive minimal training and education
in multimodality analgesic administration.
Most residents learn pain management strategies from those
surgeons who have gone before them. This trend extends to
both analgesic selection and appropriate dosing for each level of
pain severity and tends to favor opioid use. Beyond this exposure, junior-level resident pain management strategies typically
are subject to trial and error, often with arbitrary increases or
decreases in dosages based on the subjectively reported level
of pain, with the addition of nonopioid analgesics chosen in a
“dealer’s choice” fashion. Patients with preoperative chronic
pain or with symptoms that fail to be controlled with conventional methods are often referred to pain management
specialists while they are in postoperative recovery.
To mitigate the growing crisis, surgeons need to develop a
deeper understanding of the relationship between symptoms,
prescribing patterns, educational interventions, and subsequent
outcomes. The University of Toronto, ON, has instituted a
multidisciplinary transitional pain service to manage patients
with chronic postoperative pain and reduce opioid use.
university’s pain research unit found that 70 out of 200 consecutive patients continued to have pain at three months, and
researchers noted continued use of oral opioid agents in 27 percent of postoperative patients with persistent pain. Although
these patients reported pain levels that were lower than those
patients taking nonopioid agents for persistent pain, opioid
users reported lower overall health, mood, and ability to return
to work. Although the findings presented by the University of
Toronto’s pain research unit highlight important issues surrounding over-prescribing of narcotics to postoperative patients,
insufficient attention is paid to the risk of developing dependence or chronic postoperative pain, let alone strategies for
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