Chapter 10: Pain Medicine 2026

 Dr Jane Quinlan, Ms Samantha Lai Sheung Ma

Why do this quality improvement project?

Opioids are commonly and appropriately used in hospitals to manage acute pain after surgery, trauma, or inflammatory processes, as part of multimodal analgesic plans.  Opioid stewardship refers to a systems-wide approach of coordinated interventions designed to improve, monitor, and evaluate the use of opioids to support safe use¹. Analgesic stewardship expands this concept further to encompass the safe use of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and other analgesics². This quality improvement project is designed to monitor the effectiveness of the stewardship programme and identify areas for improvement.

Background

The international consensus statement on the prevention of opioid-related harm in adult surgical patients³, and the Faculty of Pain Medicine’s publication “Surgery and Opioids: Evidence-Based Expert Consensus Guidelines”⁴ were both developed to provide balanced guidance on the safe peri-operative use of opioids, facilitating optimal functional recovery while reducing the risk of opioid-related harm in adult surgical patients. The main risks of postoperative opioids include opioid-induced ventilatory impairment (OIVI) (with associated mortality) and persistent postoperative opioid use (PPOU). Modified-release opioids increase the risk of OIVI and PPOU and are no longer supported for the management of postoperative pain⁵.

Variation in opioid prescribing is particularly concerning on discharge home, with many patients being dispensed more opioid than is required, risking OIVI, PPOU (with the danger of dependence and addiction), diversion and accidental overdose⁶. The severity of pain after different surgical procedures means that discharge prescribing should be procedure-specific and tailored to the specific patient needs.

Best Practice

1. The establishment of a hospital multidisciplinary opioid stewardship group (OSG) with representatives from: pharmacy; inpatient pain service; ward nursing teams; clinicians from surgical, medical, and ED areas; ERAS nurses; resident doctors; palliative care team; primary care teams; clinical governance; medical director. The OSG should address analgesic prescribing incidents, including naloxone administration or ICU admissions for opioid toxicity, and guide educational and institutional interventions to improve analgesic safety.

2. All patients receiving opioids for acute pain should be assumed to be at risk of developing PPOU and OIVI, with their level of sedation assessed at appropriate and repeated intervals.

3. Provision of analgesia should be multimodal, incorporating non-opioid analgesia and non-pharmacological techniques, and guided by functional outcomes such as the functional activity scale ⁷, rather than unidimensional pain scores alone.

4. Long-acting (modified-release) opioids should not be used routinely for acute postoperative pain.

5. A patient-centred approach should be used to limit the number of tablets and the duration of usual discharge opioid prescriptions, typically to less than a week.

6. Patients should be advised on safe storage and disposal of unused opioids and directed to avoid opioid diversion to other individuals (e.g. sharing with friends and family).

7. Individualised post-discharge tapering plans should be embedded into discharge summaries.

Suggested Data to Collect

Pre-operatively

• Number of patients taking opioids pre-admission, and the number who are then identified to the Inpatient Pain Service 

In-hospital phase, including postoperative period

• Percentage of patients (without contraindications) receiving paracetamol and NSAIDs as part of their pain management plan (standard: 100%)
• Percentage of patients receiving opioids who are being monitored for sedation, and co-prescribed naloxone (according to local guidelines) (standard: 100%)
• Initiation of modified-release opioids in opioid-naïve patients (standard: 0%)
• Percentage of patients whose pain is assessed using functional measures in addition to subjective pain scores (standard: 100%)

Discharge from hospital

• Number of patients with documented opioid tapering plan on discharge (standard: 100%)
• Number of patients given advice on safe storage and disposal of discharge opioids (standard: 100%)
• Number of prescriptions with clear instructions to General Practice teams about intended and expected duration (standard: 100%)
• Incidence of Readmission, ED attendance or contact with primary care for opioid-related adverse events (standard: 0%)
• Discharge opioid data by ward or specialty to identify high-prescribing areas

Quality Improvement Methodology 

• Opioid stewardship is a complex process involving many components of the patient's journey, so areas for improvement will vary from healthcare system to healthcare system.
• To understand where improvement efforts are best placed, an understanding of the state of the local system is needed. Use audit or service evaluation techniques to establish quantitative baseline data, including prescribing data from electronic systems if available. Triangulate this with qualitative data such as staff surveys to assess understanding of, and compliance with, areas of best practice, and reviewing incidents reported to local governance processes, to deepen understanding and establish priority areas to work on.
• Establish a multidisciplinary OSG to supervise improvement work and enable more effective understanding of the pathway from many points of view.
• Consider process mapping the areas being worked on for improvement, for example if patients are not being identified pre-operatively and flagged to the pain team, work with the preoperative nurses and anaesthetists to understand the system as it is currently functioning
• Consider creating a driver diagram to build a model of potential areas influencing the process and think about changes that could be made to influence the system from a wide set of areas.
• Use Plan-Do-Study-Act cycles, reviewed by the OSG, to monitor progress and how changes are impacting the system
• Consider using run charts, or statistical process control charts, to monitor quantitative data over time, to understand the impact of changes, and whether change is sustained.

References

1.Specialist Pharmacy Service. Developing opioid safety across a system. SPS; 2025 March 26. Available from: https://www.sps.nhs.uk/articles/developing-opioid-safety-across-a-system/

2.All Wales Therapeutics and Toxicology Centre; All Wales Medicines Strategy Group; All Wales Prescribing Advisory Group. All Wales Analgesic Stewardship Guidance. Wales: NHS Wales / Welsh Government; 2022. Available from: https://awttc.nhs.wales/files/guidelines-and-pils/all-wales-analgesic-stewardship-guidancepdf/

3.Levy N, Quinlan J, El Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, et al. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia. 2021;76(4):520–36. doi:10.1111/anae.15262

4.Srivastava D, Hill G, Carty S, Goodwin R, De Beer J, Levy N, et al. Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom. Br J Anaesth. 2021;126(6):1005–17. doi:10.1016/j.bja.2021.02.030

5.Medicines and Healthcare products Regulatory Agency. Prolonged-release opioids: Removal of indication for relief of post-operative pain. GOV.UK: 2025 March 12. Available from: https://www.gov.uk/drug-safety-update/prolonged-release-opioids-removal-of-indication-for-relief-of-post-operative-pain

6.Reed ZK, Ma SLS, Ramadan H, Flewitt EW, Hasler N, Hussey A, et al. Exploring take home opioid stewardship (ETHOS) in UK postoperative patients. Br J Pain. 2025 Apr 20. doi:10.1177/2049463725133664. PMID: 40264924; PMCID: PMC12009848

7.Scott DA & McDonald WM (2008) Assessment, measurement and history. In: Clinical Pain Management: Acute Pain 2nd edn. Macintyre PE, Rowbotham D and Walker S (eds). London, Hodder Arnold.