Postoperative Pain Management in Rural Communities
Prevention
Research indicates that significant clinically unnecessary overprescribing of opioids after surgery has occurred in the U.S.¹ Our center is partnering with hospitals in rural New York to adapt and implement best practices to reduce clinically unnecessary opioid prescribing after surgery while ensuring that patients’ pain is appropriately managed. We engage with both providers and patients in this initiative in the following areas:
Providers
Best practices for postoperative opioid prescribing
Non-opioid approaches to pain management after surgery
Data dashboard to review prescribing patterns
Tools for communicating with patients about managing pain
Patients
Education about the role of opioids in managing pain
Education about the risks of opioid use and symptoms of potential/early onset opioid use disorder (OUD)
Education about non-opioid approaches to pain treatment
Education about opioid overdose prevention (naloxone)
Information and tools for safe disposal of unneeded medication
An important aspect of the project is equipping patients with knowledge and agency to make decisions about their pain treatment. In addition to providing education, the surgical team establishes relationships with patients so they feel comfortable working with the team on postoperative pain management and reaching out with questions during their stay and after they go home.
Prescription opioids and the OUD crisis
The significant increase in opioid prescribing in the 1990s and 2000s was in response to initial findings that pain was not being adequately assessed and treated in our health care system. The medical community, government agencies, and accrediting organizations developed pain management measures and standards and encouraged more robust treatment. At the same time, pharmaceutical companies’ marketing campaigns and studies lacking strong methodology stressed that prescription opioid medications did not pose significant risks. These factors contributed to a climate in which providers and patients expected to achieve close to zero pain after surgery.²
Globally, opioid prescribing more than doubled between 2001 and 2013,³ and in the U.S. opioid prescribing quadrupled between 1999 and 2010. During that period, rates of OUD among individuals taking prescription opioids increased, and overdose deaths involving prescription opioids rose dramatically.⁴ Between 1999 and 2020, approximately 565,000 Americans lost their lives to opioid-related overdose.⁵
While opioid prescribing accelerated rapidly, consensus on appropriate prescribing practice has been slower to develop.⁶ In the absence of evidence-based guidance, postoperative prescribing rates have varied widely for the same procedures, even within the same hospitals. A study looking at hospital data from a six-month period in 2016-2017 found that 91% of patients in the U.S. were prescribed opioids after surgery versus 5% of patients in other countries after the same procedures, and the number of pills per prescription was significantly higher in the U.S.⁷
Clinically unnecessary overprescribing of opioids after surgery is associated with increased risk for persistent opioid use as well as diversion of medication.⁸ Six to 10% of patients without a history of opioid use who receive opioids after common procedures continue to fill prescriptions 3–6 months after their surgery. Furthermore, 92% of opioids prescribed by surgeons are not used,⁹ making them potentially available for diversion.
Establishing prescribing guidelines
In 2016, the Centers for Disease Control and Prevention (CDC) released a clinical practice guideline on prescribing opioids for pain that focused on treatment of chronic pain by primary care providers.¹⁰ The CDC published an updated guideline in 2022 that expanded the scope to other clinicians and to outpatient care for adults with acute pain (lasting less than 1 month) and subacute pain (lasting 1–3 months). This guideline emphasizes effective communication with and empowerment of patients around pain management and a multimodal approach that draws on opioid and non-opioid medications and other therapies as appropriate for a specific patient.¹¹
Medical and academic organizations have been developing evidence-based guidelines for opioid prescribing after surgical procedures. These include key guidelines published by the University of Michigan Opioid Prescribing Engagement Network (OPEN).¹² The OPEN consortium used “data analysis, literature review and expert consensus” to develop evidence-based, procedure-specific recommendations for postoperative opioid prescribing. OPEN also provides education and resources for providers and patients about opioids and on non-opioid pain management strategies.¹³
Drawing on OPEN, in 2017-2018 the University of Rochester Medicine Department of Surgery adopted an opt-in opioid prescribing process for cervical endocrine surgery. The surgical team provided education to patients about pain management and opioid risk and encouraged them to work with the team to decide whether to go home with an opioid prescription. Given the choice, most patients decided to opt out: The percentage of patients discharged with opioids decreased from 100% to 4.2% compared to previous practice. There was a 96.6% decrease in the number of pills prescribed and a 98% reduction in unused pills.¹⁴
The success of this program led to a wider initiative in the Department of Surgery to reduce clinically unnecessary opioid prescribing, with leadership by Jacob Moalem, MD. Data dashboards, procedure-specific benchmarks, and educational materials for clinicians and patients were key elements of this initiative.¹⁵
Rural implementation
In 2022 our Rural Center of Excellence began to adapt the Department of Surgery program (established in an urban medical center) for implementation in rural communities. We partnered with four University of Rochester Medicine rural hospitals in New York’s Southern Tier region and their affiliated clinics and practices, adapting processes and resources to their needs: Jones Memorial (Wellsville), Noyes Memorial (Dansville), Noyes (Geneseo), and St. James (Hornell).
In adapting the program with rural hospitals, our center’s project team, led by Theodor Kaufman, MD, chief of regional surgery, has emphasized building and maintaining trust and close partnership with project champions, surgical faculty, and staff in the region. Our partners’ insights have shaped project materials. This emphasis on rural staff and providers’ experiences has been a hallmark of our working relationship, allowing our center, which is located in an urban area, to be guided by rural strengths and needs as we work to adapt and implement the project.
Initial data analysis showed variation in postoperative prescribing among hospitals, within hospitals, and within service lines in the region. We teamed up with surgeons and other health care providers to establish and apply evidence-based, procedure-specific, and clinically appropriate opioid prescribing benchmarks. These guidelines are based on OPEN recommendations with input from physicians and departments at our partner hospitals and attention to internal metrics. For procedures on which OPEN guidelines have not been established, we work with surgical teams to develop internal evidence-based guidelines.
Our frequently updated data dashboards show prescribing patterns to support physician learning and implementation. Prescribing guidelines are featured on staff badges and posters for easy reference, and the electronic medical record prompts providers to assess the clinical necessity of opioids on a case-by-case basis. We work with surgeons and care teams to optimize the use of non-opioid medication and other pain-management strategies in postoperative care. In addition, we track opioid prescribing and pain-management effectiveness continually to refine benchmarks and maintain consistent implementation across hospitals, services lines, and providers as we ensure patients’ pain is appropriately managed.
Patient empowerment
Patient engagement begins before surgery—letting patients know what to expect, including that pain after surgery is normal and usually temporary—and it continues during their stay and after they go home.
Our work in this area led us to shift away from use of a 0–10 numerical pain scale when asking patients to report their pain. Research has pointed to negative repercussions from a heavy reliance on numerical pain scales and the importance of setting realistic expectations and functional goals when asking patients to describe their pain and assessing clinically appropriate opioid prescribing levels.¹⁶ Moreover, partnering providers in the Southern Tier region shared concerns that the 0–10 scale could lead to clinically unnecessary prescribing. In addressing these concerns, we collaborated on an adapted tool that would be more accessible to patients and help them describe their pain more accurately. Rather than 0–10, which may carry an expectation of zero pain, we use a scale indicating that mild-to-moderate pain is normal after surgery. This tool fits into broader discussions with patients about expectations and goals for pain management.¹⁷
We provide training and tools to help surgical teams communicate with patients effectively about managing their postoperative pain, risks associated with opioid use, and alternative pain-management approaches. Resources for patients—including a video with providers from the region, poster, and handout—provide key information and support. Patients are given the option to go home after surgery without an opioid prescription. They are encouraged to contact the care team if they have questions or concerns.
Transcript
“Comforted”
“Cared for”
“Safe”
“Heard”
“This is what we as a surgical team want all of our patients to feel. As a Region, we are totally committed to providing the best care for our patients. Beyond the excellent care that you will receive in the operating room, we will work hard to keep you both comfortable and safe. A few years ago, the goal was to try to completely eliminate pain after surgery,
often using large amounts of opioid medications.”
“But multiple recent studies have revealed that most of the opioids that were prescribed were actually unnecessary, and that this over prescription increased the risk of opioid addiction, dependence, and diversion of unused pills into the community.”
“If you notice yourself taking more medication than prescribed, are running out of prescriptions earlier than indicated, are having thoughts of wanting to take more opioids, or are seeking opioids from sources other than your doctor, please call your surgical team to discuss if you may be developing early signs of substance use disorder. Your surgical team is here for you and will connect you to the care that you may need.”
“It is our responsibility as your surgical team...”
“As your nurse...”
“As your pharmacist...”
“As your advocate- to take this risk seriously, and do what we can to minimize your exposure while keeping you comfortable after surgery.”
“Surgery causes pain but with the appropriate mindset and tools we can manage it very well. We must first acknowledge that you will have some discomfort after surgery. Our goal is to reduce your pain to a level which allows you to function normally. For most people this is around a 3 or a 4 on a 10-point pain scale.”
“In the hospital and after discharge, we should not aim for a pain score of zero, or take opioid medications ‘just in case’.”
“Various non-opioid medicines like Tylenol and Ibuprofen are very helpful in treating post-operative pain and reducing your need for opioids. Local pain control methods, such as use of lidocaine patches, ice or heat can also be used in some cases.”
“Opioid medicine may be helpful for pain that is not adequately controlled by these other modalities. Depending on
the procedure that you had, your surgeon will discuss with you an effective plan tailored to your post-operative needs."
“Our goal is to work with you to create a pain plan of care to allow for normal function with the understanding that some pain may still exist but won’t prevent you from living your day-to-day life. If you find your pain is not being treated in a way where you can comfortably perform these activities with the amount you have been prescribed, please contact your surgical team to discuss additional pain management approaches.”
“If you have unused opioid pills after recovering from your procedure, we strongly encourage you to safely dispose of them to prevent children or others from accessing these medications which can cause an overdose when not taken as prescribed, or by whom they were prescribed to. Narcan, a medication to reverse overdose, can be provided to you at any time by discussing with a pharmacist or your doctor.”
“At discharge, your surgical staff will send you home with a Deterra bag, which is an environmentally safe way to make your prescriptions inactive, and a safe disposal method. You can also bring your unused pills back to some pharmacies,
such as participating Wegmans, CVS and Walgreens pharmacies, as well as local police stations and they will dispose of these pills for you.”
“Throwing opioids directly into the trash or flushing them down the toilet is not a safe or proper way to dispose of these pills. If you do not have a Deterra bag, or are unable to return unused medications, these pills can also be mixed with kitty litter, dirt or coffee grounds, placed in a sealed plastic bag, and then thrown in your trash at home as a safer alternative disposal method.”
“We are ready to support you through every step of your surgery and recovery. Thank you for allowing
us to care for you, and for partnering with us to reduce opioid overuse and over prescription.”
Another priority is informing patients about safe disposal methods for unused medication should they receive a prescription. Patients are provided a Deterra bag (other medication disposal pouches may be used or recommended) and instructions on disposing of any unused medication to reduce the risk of diversion into the community. For patients who go home with opioids, education about overdose prevention and naloxone medication are also important.
Currently we are expanding implementation of this approach beyond our Southern Tier partnership by teaming up with hospitals in New York’s Finger Lakes region.
Sharing what we have learned
As we bring this project to other rural communities and providers, we make it a priority to collaborate with administrators, departments, clinicians, and staff to tailor the program, educational materials, and messaging to each partner’s unique needs.
We will broadly share tools, resources, and learnings with rural communities across the country. Please visit the toolkit on this page to browse current resources, and contact us at Program Assistance if you would like to learn more.
Our team
Theodor Kaufman, MD, FACS: Faculty lead, University of Rochester Medicine regional surgery division chief and associate professor of clinical surgery
Katherine Connelly, MPH: Project manager
Jack Bramley, MS: Senior data scientist, University of Rochester Medicine Quality Institute
References
¹ Neuman, M. D., Bateman, B. T., & Wunsch, H. (2019). Inappropriate opioid prescription after surgery. Lancet, 393(10180), 1547–1557, p. 1549.
² Neuman et al. (2019), p. 1547; Kaafarani, H. M. A., Han, K., El Moheb, M., Kongkaewpaisan, N., Jia, Z., El Hechi, M. W., van Wijck, S., Breen, K., Eid, A., Rodriguez, G., Kongwibulwut, M., Nordestgaard, A. T., Sakran, J. V., Ezzeddine, H., Joseph, B., Hamidi, M., Ortega, C., Flores, S. L., Gutierrez-Sougarret, B. J., Qin, H., … Lillemoe, K. D. (2020). Opioids after surgery in the United States versus the rest of the world: The international patterns of opioid prescribing (iPOP) multicenter study. Annals of Surgery, 272(6), 879–886, pp. 879–880.
³ Neuman et al. (2019), p. 1547.
⁴ Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain – United States, 2022. Morbidity and Mortality Weekly Report. Recommendations and Reports, 71(3), 1–95, p. 3.
⁵ Congressional Research Service (CRS). (2022). The opioid crisis in the United States: A brief history, p. 1.
⁶ Neuman et al. (2019), p. 1552; Sullivan, M. D. (2021). Opioid overprescribing or underprescribing after surgery? Mayo Clinic Proceedings, 96(5), 1108–1110, p. 1108.
⁷ Kaafarani et al. (2020), pp. 879–880, 882–883, 885.
⁸ Kaafarani et al. (2020), p. 882.
⁹ Overdose Prevention Engagement Network (OPEN). Your prescription makes a difference. Retrieved December 12, 2025.
¹⁰ Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain — United States, 2016. Morbidity and Mortality Weekly Report. Recommendations and Reports, 65(1), 1–49.
¹¹ Dowell et al. (2022), pp. 4–5, 7, 17.
¹² Neuman et al. (2019), pp. 1551–1554.
¹³ OPEN. Pain management and Surgery pain management. Retrieved December 12, 2025.
¹⁴ Ruffolo, L. I., Jackson, K. J. L., Chennell, T., Glover, D. N., Argenio, A. L., & Moalem, J. (2018). Narcotic-free cervical endocrine surgery: A shift in paradigm. Journal of the American College of Surgeons, 227(4), e143–e149, pp. e143–e146.
¹⁵ Moalem, J. (2022, May 18-20). UReduces: University of Rochester’s opioid stewardship program [Conference presentation]. Taking Action Summit, Rochester, NY, United States.
¹⁶ Baker, D. W. (2017). History of the Joint Commission's pain standards: Lessons for today's prescription opioid epidemic. JAMA, 317(11), 1117–1118; Levy, N., Sturgess, J., & Mills, P. (2018). "Pain as the fifth vital sign" and dependence on the "numerical pain scale" is being abandoned in the US: Why? British Journal of Anaesthesia, 120(3), 435–438.
¹⁷ We adapted the 4 point verbal rating scale, where patients describe their pain using the terms none, mild, moderate, or severe. Rather than using none, which suggests zero pain, we shifted to the term “no discomfort.” We also opted to highlight the mild-to-moderate range to stress the range expected after surgery. For a discussion of pain scales, including numerical and 4 point verbal rating scales, see Levy et al.
