Standardizing Stepwise Perioperative Opioid Administration in CRC Care

When treating patients experiencing pain, Ronald Bleday, MD, co-director of the Colon and Rectal Cancer Center at Dana-Farber Cancer Institute and 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, suggests that patients begin on a non-narcotic before being administered opioids in a conversation with CancerNetwork®.

Contextualized by a retrospective cohort study published in the Journal of Surgical Research exploring enhanced recovery after surgery (ERAS) pathways in limiting perioperative opioid use following surgery for colorectal cancer, Bleday discussed how a multi-disciplinary pain management approach can play into the perioperative care of patients experiencing varying levels of pain while mitigating opioid use. He began by suggesting that ensuring uniform standards for practice, particularly across treatment divisions, is necessary to avoid overtreatment with opioids.

In his practice, Bleday explained that before implementing a uniform stepwise surgical pain approach, physician assistants would preemptively give opioids before the onset of pain. He expressed that a significant amount of education was required to implement a stepwise strategy and initially treat with a non-opioid for the onset of pain. Bleday concluded by highlighting anesthesiologists at his practice, who utilize long-acting opioids on an as-needed basis to help mitigate overuse.

Transcript:

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, residents, all 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 non-narcotic first.

It was a lot of education for the providers––nurses, advanced practice providers [APPs], and surgeons––early on, to get them to buy into 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 [and] helped us with.

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