How I Avoid Prescribing Strong Opioids

I haven’t prescribed any opiate stronger than codeine in over 3 years. Before that, my routine post-operative prescription was hydrocodone, which was fairly standard for U.S. orthopaedic surgeons. But after learning of the gross disparity in postoperative narcotic prescriptions here compared to other countries and given the changing attitudes in America regarding post injury/postoperative pain control, I was able to significantly reduce the strength of my opioid prescriptions.

Although my practice is mostly outpatient arthroscopy, I also perform ORIF/IM nailing of upper and lower extremity fractures, and also shoulder replacement surgery – all without prescribing any post discharge opiate stronger than codeine. Do some patients call regarding pain control? Sure, but no more so than when I routinely prescribed hydrocodone. Moreover, I haven’t detected any difference in pain during postoperative visits since changing my prescribing practices.  

I’ve been using a multi-modal approach to control postoperative pain for many years, so what allowed me to change my opiate prescribing can’t be attributed to that strategy. What I think really worked is educating my patients that:

1.    Some pain following injuries/surgeries is normal and should be expected.
2.    Analgesics typically only reduce pain, not eliminate it altogether.  
3.    It’s important not to let pain build too much before taking analgesics, especially in the early postoperative period.  

As I think it’s important that patients believe their doctor cares about their discomfort, I never delegate this conversation about pain control, and spend additional time going over point #3, above.

Omer Ilahi, MD
[email protected]

Further Reading: AAOS Pain Relief Toolkit

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