Nurses Are Key to Reducing Opioid Use After Colorectal Surgery

Ronald Bleday, MD

A step-wise approach to pain management has led to a significant reduction in narcotic use following colorectal surgery with support from nursing staff, who are often the first point of contact for patients when pain arises, according to Ronald Bleday, MD.

In an interview with Oncology Nursing News, Bleday explained that this model emphasizes minimizing opioid use while ensuring adequate pain control through multimodal strategies and careful nursing involvement. He noted that a cultural shift has occurred, moving away from the old paradigm of “getting ahead of pain” with narcotics toward standardized prescribing practices, regionalization of care, and prioritizing non-narcotic options.

Nurses, he emphasized, are central to this process. At the bedside, they are often the first to assess pain, initiate supportive measures, and communicate patient needs to the broader care team. Their experience also plays an important role in predicting which patients are most likely to require narcotics, particularly those with metastatic disease or bone involvement. For newer clinicians, mentorship from experienced oncology nurses and advanced practice providers can help ensure safe, consistent pain management while reducing unnecessary opioid exposure.

Bleday is co-director of the Colon and Rectal Cancer Center at Dana-Farber Cancer Institute and section chief of the Division of Colorectal Surgery at Brigham and Women’s Hospital in Boston, Massachusetts.

Oncology Nursing News: How has a step-wise model helped reduce opioid use after colorectal surgery?

Bleday: The residents, physician assistants, and the nurses are going to be the first to hear the complaint about pain. What we’ve been able to do is break the practice of saying, “Let’s get ahead of your pain,” because that is oftentimes just unnecessary. Narcotics are being given when the patient may not have a lot of pain or will have pain that can be taken care of with either intravenous or oral, non-narcotic medications.

The second thing is that the amount given on discharge has also been standardized. That was huge, because there were a lot of patients that didn’t need 30, 40, or 50 pills. Now that it’s all been standardized, that has helped reduce a lot of the problems in the community [setting]. We’ve gotten everybody on board with nursing to try to have patients minimize the amount of narcotics.

There has been a huge culture change. When we instituted these practices, the whole country was going from the thought that pain is the fifth vital sign, to minimizing narcotics. The patients are also good partners in this. Sometimes they refuse narcotic pain medicine, which, most of the time, is fine, because we have other tools to reduce their pain. Sometimes they do need a little because it’s physiologically hurting in the incisional pain. But the patients have been terrific over the last 5 to 8 years at buying into “getting rid of as much pain as possible, but without narcotics.”

What role do oncology nurses play in assessing and managing pain in these patients?

The nurses at the bedside are the first people that a patient asks for any pain medication, so nurses need to be included on the team and educated as to how we, as clinicians, would like our patients to get their pain control.

There are adverse effects (AEs) to each tool that you use to control pain. The blocks can have AEs, the non-narcotic medicines, and, of course, the narcotics. What has really helped is regionalization. Most of our patients go to a floor where the nurses are used to taking care of gastrointestinal surgery patients, so they know the usual rhythm of when pain is the worst. They also know the stepwise approach that we as clinicians are familiar with, which they can offer to the patients.

[We can] always having a narcotic as rescue, but use it as a last resort. This has helped significantly in regionalization because the type of pain that you get after orthopedic surgery is going to be a little bit different than the type of pain you get after colorectal surgery. Working with the nursing leaders, initially, then with all the frontline nurses, we have been able to get everyone on the same page to give good pain control but also to minimize narcotics.

What role do nurses play in providing narcotic pain management only to those who need it?

Oncology nurses are going to know which type of patients are going to go down a path where they may need more pain medicine, including opioids, than patients who will not. If you have a patient who does not have metastatic disease (who oftentimes have gotten through surgery and are not on opioids post surgery), they are unlikely to need any opioids with neoadjuvant or adjuvant chemotherapy.

However, if you see a patient with metastatic disease, particularly metastatic disease to the bone, you know that the patient is going to have increasing needs for pain control, often with large doses of a narcotic. The experience and knowledge that come with getting to know the pathways that different patients with cancer go down in their treatment is very helpful. For the experienced nurses and APPs, to pass on that instinct and that knowledge to the new “rookies” coming into the care of patients with cancer would be the best thing that they can do for the care of these patients.

This transcript has been edited for clarity and conciseness.