The American Society of Anesthesiologists (ASA), along with 14 medical specialty organizations including the American Society of Plastic Surgeons, has established seven guiding principles to better address the perioperative treatment of acute pain in complex surgical patients. The principles were established during a second-of-its-kind pain summit hosted by ASA.

“Every surgical patient deserves adequate pain relief that aims to prevent opioid reliance, chronic pain and other negative outcomes, but it may be more challenging to achieve this in certain patient populations,” says ASA President Randall M. Clark, MD, FASA. “The new principles were created to build upon an original set established last year during our first pain summit, but specifically address patients undergoing surgery with chronic pain, those taking opioids preoperatively, and those with substance use disorders. 

“The new principles give the perioperative care team more guidance to care for these particularly complex patients,” Clark adds.

In February 2021, ASA convened 14 medical specialty organizations for a virtual pain summit to collaborate on a resource for acute surgical pain care. The participating organizations reached consensus on seven foundational principles for the perioperative treatment of acute pain, published in Regional Anesthesia & Pain Medicine

The seven new principles, which will be developed into a resource for clinicians and other care team members, recommend:

  1. If clinicians identify a positive screen for substance use preoperatively, a more detailed assessment tool should be utilized to risk stratify patients for additional support or referral for treatment when indicated.
  2. In conducting a preoperative evaluation, if a patient is identified as having chronic pain, opioid tolerance, or a substance use disorder, clinicians should coordinate with the patient’s care team, including consultation with a pain medicine, behavioral health, or addiction medicine specialist.
  3. For patients on long-term opioid therapy preoperatively, clinicians should coordinate with the patient’s prescribing clinician and continue the baseline opioid dose in the perioperative period with supplemental analgesia as needed for postoperative acute pain.
  4. Clinicians should work with patients who have opioid tolerance on an individualized tapering plan for postoperative opioids, coordinating with the long-term opioid-prescribing clinician, with the goal of return to the preoperative dose or lower as soon as possible.
  5. For patients prescribed opioids at discharge following surgery, clinicians should inform them and their caregivers about the risks, signs, and management of opioid-induced respiratory depression; that they must avoid concurrent use of medicines with sedative effects and alcohol while taking opioids; and when to call for emergency assistance.
  6. For patients identified as having significant risk of opioid-related adverse drug events or severe uncontrolled perioperative pain, clinicians should consult a pain specialist or anesthesiologist preoperatively.
  7. For patients identified as benefitting from additional consultation with a pain medicine, behavioral health, or addiction medicine specialist, clinicians should utilize telehealth options if in-person consultation is not available.

In addition to ASA, participating medical organizations include:

  • American Academy of Orthopaedic Surgeons
  • American Academy of Otolaryngology-Head and Neck Surgery
  • American Association of Neurological Surgeons
  • American Association of Oral and Maxillofacial Surgeons
  • American College of Obstetricians and Gynecologists
  • American College of Surgeons
  • American Hospital Association
  • American Medical Association
  • American Society of Addiction Medicine
  • American Society of Breast Surgeons
  • American Society of Plastic Surgeons
  • American Society of Regional Anesthesia and Pain Medicine
  • American Urological Association
  • Society of Thoracic Surgeons

“The next step for this multi-society consortium and effort is to establish how we can help institutions implement both sets of guiding principles into their practices,” says Clark.