Shared Decision-Making in Postoperative Pain Management

Medscape

24-07-2025

This transcript has been edited for clarity.
Jeff Gadsden, MD: Hello, I'm Dr Jeff Gadsden, a professor of anesthesiology at Duke University Hospital in North Carolina. And with me is Dr Eliana Saltzman, an orthopedic surgeon whom I work with frequently. Welcome, Eliana.
Eliana Saltzman, MD: Thank you so much for having me today. I'm really excited to be here with you.
Gadsden: It's my pleasure.
Today we're going to talk in this Care Cues conversation about having a preoperative discussion with our patients about postoperative pain management in a way that fosters shared decision-making, as well as a reduction in opioid prescriptions.
Saltzman: I am a hand and upper-extremity surgeon, so, high-volume surgery, high number of prescriptions of opioids. For me and my practice, this is a really important topic, especially as we meet patients and discuss where we go next in terms of expectations at the peri-op period.
Gadsden: Absolutely.
Partnering Against Pain
Gadsden: So, let's think about this in terms of the way that I think about surgery: There's a preoperative phase, an intraoperative phase, and a postoperative phase.
In the preoperative phase, how important is it to get with your patient and have that discussion and set expectations about what their pain management is going to look like afterwards?
Saltzman: I think it's a huge part of it: setting expectations for the patients and explaining what their postoperative course is going to look like, as well as briefing them on their intraoperative anesthetic options that they have available.
There has been a lot of research that has shown that the preoperative discussion — in terms of multimodal analgesic options — has huge ramifications in terms of the decreased number of opioid prescriptions actually taken but also patients reporting better pain scores as well.
Precision Pain Management
Gadsden: Let's get down to nuts and bolts here.
So, if I'm coming through your clinic and I'm going to get an elbow operation, what multimodal agents are you likely to prescribe for me before I even get to the OR?
Saltzman: I will ask you to take acetaminophen and ibuprofen. Alternate between the two medications and take one of those medications every 4 hours.
And I like that more than taking the same quantity of each once or twice a day, because that way you can really have something always on board every 4 hours. And, again, trying to prepare patients for that post-op period, I really try not to prescribe any opioid pre-op so that postoperatively it is as efficacious as possible.
Gadsden: Yeah, I love that. That's my magic recipe too. The acetaminophen, NSAID (nonsteroidal anti-inflammatory drug), acetaminophen, NSAID, every 3 or 4 hours, and I present that to friends and family when they have aches and pains.
Saltzman: Me too.
I think in this new era, there's a tremendous focus on the multimodal, that ibuprofen and acetaminophen should be taken routinely for the first 3-5 days after surgery and that the role of opioids should really be for breakthrough pain.
Gadsden: In the old days, we used to rely on them as our first and sometimes monotherapy, right? Have you seen a reduction in the number of patients that need any opioids?
Saltzman: For soft tissue only, small hand procedures — I like to call them procedures and not surgeries to create the mindset of this being a very small operation — there has been quite a bit of research in hand and upper extremity surgery to understand that if you are going to prescribe an opioid, how many do you need to prescribe?
Because it's not the same for every patient. On the basis of age, length of procedure time, whether it's soft tissue or bony, that number should really be different. Rather than in the old days when everybody got a huge number of opioids no matter what the procedure was.
Gadsden: Yeah. I used to see 90 pills going home with patients every day.
Saltzman: 120 for a total knee replacement was not uncommon.
Gadsden: Right. So, what I hear you saying is that we're moving towards an era of more precision pain management where you tell patients, 'Alright, you're getting this operation, so I'm going to give you my usual multimodal regimen plus six oxy.'
Saltzman: Even five. Or none. I mean, I have a lot of patients say, 'I really don't want any,' and I think that's absolutely fine.
Sometimes I'll still send it to the pharmacy so it's there for them. So, we've really swung in the other direction, which is great, but sometimes it can leave patients in that acute post-op period without any coverage.
Staying Ahead of Pain
There's this whole concept around being behind pain or chasing your pain. How do you manage that? Or what does that conversation look like for you?
Gadsden: When I trained back in the 1900s, the common wisdom was: get pain, take some opioid, take some more opioid, take some more opioid. And of course, that wisdom has led us down the path to where we are today with the opioid crisis. And so, the idea of never letting someone have pain is a little bit obsolete.
I think we've tweaked that a bit with a focus on the multimodal. So, to your point earlier — if you take acetaminophen, NSAID, acetaminophen, NSAID — that's a good thing to stress getting in there early and really making sure that you never miss those doses rather than saying you have to take opioids and never have pain.
Expanding the Toolbox
Saltzman: Are there any other novel therapies that you think are coming about or other ways that we can help control our peri-op, post-op pain?
Gadsden: There are some new things coming down the pike that are showing a lot of promise. A drug that comes to mind is one called suzetrigine, which is a pill you can take for a week or two after surgery. It works on the same sodium channels that we would target with a nerve block. But instead of getting a numb hand and a hand you can't move, it only targets the pain fibers. And so, you can move your hand and you can feel your hand, but you don't have pain or you have less pain. So that's exciting.
Saltzman: And that's just for acute pain or patients who also have chronic pain?
Gadsden: Both acute and chronic pain for that type of drug. And then another exciting one that we're using now currently at Duke is cryotherapy. So, the idea is you take a device and with ultrasound guidance, put the tip of a needle next to a nerve, press a button, and an ice ball forms near the nerve and in effect deactivates it. The nerve grows back over time, but it takes weeks and weeks and weeks and sometimes people get pain relief for months out after cryotherapy.
In Patients' Hands
Saltzman: So now we have all these amazing new modalities and this multimodal pain regimen. How has that translated as we've moved more and more patients to become postoperative outpatients, either going home the same day or being in-patients for much shorter hospitalizations?
Gadsden: When I was in residency, you did a total knee replacement on someone and they would stay in the hospital for 5 days. Giving someone an opioid in a hospital setting is in many ways a much safer proposition than if you send someone home with the same opioid. The switch to a much more ambulatory style of practice has put different challenges and stresses on our decision making.
And certainly, it fits in nicely with that idea of giving a voice to the patient. Asking them: You're going to be at home, you're not going to have a nurse knocking on your door every 4 hours. How do you see us managing your pain in a way that works best for you, your schedule, your home, and that sort of thing?
Giving Patients the Choice
Gadsden: I'm interested in the concept of shared decision-making, but have you heard of cases where the shared decision-making wasn't quite so great and there was a downstream consequence?
Saltzman: There are patients who I've met who are really unhappy with prior surgeons who say, 'No one even gave me a choice. I didn't even know I could have it just with a block or just with local. Like I would have picked this.'
Sometimes patients can't make that decision in the clinic, which is fine. And getting to go home, think about it, read more about the various options, and then come the day of surgery saying, 'Okay, I've made up my mind.' Or, 'I'd really like to talk to the anesthesiologist a little bit more about these different options and what my postoperative course might look like.' And I think letting them decide always leads to happier patients who feel like they have more control of their postoperative course.
Gadsden: There's no question in my mind that giving patients agency and making them feel like, "I have a stake in this. I've got skin in the game now. I want to know all the facts, what my options are, and make a decision," helps with their satisfaction afterwards.
Saltzman: Yep.
Gadsden: Well, Dr Saltzman, as always, it has been a huge pleasure to talk to you about this topic that we're so passionate about: keeping people safe and keeping people comfortable.
Saltzman: Thank you again for inviting me today. It was great chatting with you.
Gadsden: Likewise.