Optimizing Stepwise Pain Relief Management in the Perioperative GI Setting

Ronald Bleday, MD, discussed his experience in treating patients experiencing pain with a stepwise enhanced recovery after surgery approach.

Implementing stepwise pain relief post surgery may help manage acute pain without opioids and mitigate opioid use in patients experiencing chronic pain, according to Ronald Bleday, MD.

In an interview with CancerNetwork®, Bleday, codirector of the Colon and Rectal Cancer Center at Dana-Farber Cancer Institute, vice chair for quality and patient safety in the Department of Surgery and section chief of the Division of Colorectal Surgery at Brigham and Women’s Hospital, and associate professor at Harvard Medical School, discussed his experience in treating patients experiencing pain with a stepwise enhanced recovery after surgery (ERAS) approach. The conversation was contextualized by a retrospective cohort study exploring whether nonnarcotic medications were associated with a decrease in long-term opioid use among opioid-naive patients in the perioperative setting following colorectal surgery.

He began by highlighting the rationale for conducting the study, which he states was born out of an observance of patients taking opioids well past the perioperative period, focusing specifically on patients who were opioid naive prior to surgery. Bleday further explained that the study pushed his institution to adopt standardized practices for perioperative pain management, emphasizing the amount of medicine given across his enterprise. Additionally, he discussed risk management among patients on an individual basis as well as a collaboration between practitioners and a chronic pain team to help patients who develop an opioid dependency.

Bleday then touched upon patient education, outlining the stepwise nature of pain relief treatment, which initially begins with pain blocks, such as transversus abdominis plane (TAP) blocks, followed by nonnarcotic medication, with narcotic medication considered as a rescue measure when the previous treatments fail. He concluded the conversation by discussing future implications for nonnarcotic development, which might help effectively treat pain while mitigating adverse effects in these patients.

CancerNetwork: What was the rationale for conducting the retrospective cohort study assessing ERAS pathways to limit perioperative opioid use?

Ronald Bleday, MD: One of the things we saw in our patients many years ago and leading up to the beginning of the study was that they would still be on opioids well past the perioperative period, when there theoretically was no incisional pain. That got us looking at our results of [the number of] patients on opioids 1 month, 3 months, and 6 months after patients had a routine colectomy. We divided the retrospective assessment into 2 groups: those who were opioid naive in the year prior, those who had been on some pain medicine, and patients with chronic pain. We primarily looked at those patients who were opioid naive as they came into their surgery.

What were the study’s key findings, and what implications do they hold for clinical practice?

The main [finding] was that it forced us to have across the whole enterprise—and there are now 18 colorectal surgeons in the enterprise—a standardized plan about how to approach a patient preoperatively and set expectations of working with our nurses and anesthesiologists on when and what to give preoperatively and during surgery to minimize the amount of long-acting opioids that are being used. Then, particularly with our residents and our physician assistants, we need to give them a guideline for a standard amount of medications in their postoperative and discharge prescriptions. That was one of the biggest things to get throughout the enterprise: standardizing the discharge medication amount.

How should independent predictors for new, persistent opioid use be incorporated into a comprehensive presurgical assessment and shared decision-making processes regarding pain management expectations and potential opioid risk?

We divided the patients into those who have been on opioids within the past year, maybe a previous operation or some orthopedic problem that forces them to be on chronic opioids or chronic benzodiazepines. Then you need to look at those patients much more individually to see what their risk is. We also have the help of a chronic pain clinic for those patients who are on [many] opioids as they come into their elective or urgent colorectal surgery. It is making that determination of opioid naive vs nonopioid naive before the perioperative period and then, for the patients who are opioid dependent in particular, getting your chronic pain team to consult and help you during the perioperative period.

What specific educational tools or protocols have been found to be effective in your practice or practices in general to inform patients about appropriate opioid use, potential adverse effects, and the risks of long-term use following a procedure?

The first thing is that we set expectations. We describe to [patients] how we are going to control their pain. One, where we can, we’ll use minimally invasive surgery. Second, we will use pain blocks. In other words, things like TAP blocks or TAP catheters or epidurals, which provide a block to the surgical area, are used as our first line of defense against pain. We then use nonnarcotic medicines intravenously for the first day and then orally for the second day as our second line of defense. Then we let the patients know that narcotics are going to be there, but they are there for rescue if the pain block and the nonnarcotic medicines are not effective.

What role can a multidisciplinary pain management approach play in the perioperative care of patients to address both acute and chronic pain effectively while minimizing opioid dependence?

When you roll [a perioperative care strategy] out to a large enterprise, you must make sure that you get all the providers, nurses, anesthesiologists, surgeons, physician assistants, and residents on the same page. Early on, we did not have that. There [were many] times the physician assistants would say, “Well, let’s get ahead of your pain. Even though you’re not having pain, let’s give you some narcotics now.” We had to break that practice and ask, “Have patients been educated to ask for a pain medication?” Then to give a nonnarcotic first.

It was a lot of education for the providers––nurses, advanced practice providers, and surgeons––early on to get them to buy into the stepwise paradigm or approach to treating surgical pain. The other thing is that we wanted our anesthesiologists to use long-acting opioids only when needed, not to slip some in, because that had been their practice. That was something that our anesthesia champions for this project helped us with.

Is there anything else that you would like to highlight that we might not have previously discussed?

One of the things that is [quite] exciting is that narcotics have [many] adverse effects. They’re effective, but they have many [adverse] effects on the sensorium, on the [gastrointestinal] tract, and other areas. What we see coming down the pike are new nonnarcotic medications that are [quite] powerful, that are oral––not necessarily [intravenous]––that will allow us to treat those patients with chronic pain who often consume [many] narcotics with nonnarcotic medications. The future is quite bright in terms of looking at getting more patients, particularly patients with chronic pain, off chronic narcotics.

Reference

McKie KA, Malizia RA, Fields AC, et al. Long term opioid use after colon and rectal surgery. J Surg Res. 2025;311:86-91. doi:10.1016/j.jss.2025.04.019