Rethinking postoperative analgesia for day‐case surgery

We read with interest the article by Ratcliffe et al., which provides an important national snapshot of analgesic prescribing and patient reported analgesic use after adult day-case surgery in the UK [1]. The POPPY cohort is valuable because it captures actual medication use rather than prescription records alone. One point that may deserve more cautious framing is the interpretation that postoperative opioid use after more major surgery does not treat pain effectively because patients using opioids reported higher pain scores and lower quality of recovery. This association is important, but it may reflect indication as much as effect. Patients continuing opioids included those undergoing major, orthopaedic and general surgical procedures, and some had pre-operative opioid exposure or longstanding pain. In these settings, opioid use by postoperative day 7 may identify greater tissue injury, central sensitisation or unmet recovery needs, rather than showing that opioids were ineffective. Fiore et al. suggested that opioids prescribed at discharge did not reduce pain intensity and increased adverse events, but their trials involved mainly minor and intermediate elective surgery [2]. The POPPY findings may therefore be read as evidence that opioid exposure should trigger review and procedure-specific rescue planning. Another issue concerns the meaning of high satisfaction. Ratcliffe et al. indicated that more than three quarters of respondents were satisfied with hospital-provided pain relief, while 26% reported more pain than expected and 18% sought additional help, most commonly from general practice. These findings are inconsistent if satisfaction is treated as a direct proxy for analgesic adequacy. Using the international PAIN OUT registry, Schwenkglenks et al. suggested that satisfaction with postoperative pain treatment is associated with pain intensity, but also with perceived improvement, involvement in care and whether treatment seems appropriate to the patient [3]. A patient may report satisfaction because staff were kind, discharge was efficient and pain was framed as expected, while still experiencing pain severe enough to contact a doctor or pharmacist. Conversely, dissatisfaction may reflect feeling unsupported despite moderate pain. The discussion could therefore be strengthened by separating analgesic pharmacology from the broader experience of support. Rather than community services absorbing a large burden, patients could be interpreting pain trajectories and medication escalation without timely clinical feedback. The discussion rightly highlights opioid stewardship, but the results also point towards broader stewardship of non-opioid analgesia and education. Only 9% of patients reported regular non-steroidal anti-inflammatory drugs (NSAIDs) use on day 1, whereas 47% reported daily opioid use. This contrast is striking because Choi et al. suggested that, in adult outpatient surgery, NSAIDs were associated with better pain scores and fewer adverse effects than codeine [4]. The issue is not that all patients should receive NSAIDs, as contraindications remain relevant, but that low regular use may indicate an opportunity to improve counselling, prescribing confidence and patient understanding of multimodal analgesia. At the same time, 23% of patients prescribed opioids reported not using these drugs, and some additional opioids were obtained from friends or relatives. Levy et al. indicated that preventing opioid-related harm requires attention to prescribing limits, patient education, safe storage and follow-up, not merely avoidance of modified-release preparations [5]. A useful next step would be adaptive analgesia pathways following hospital discharge. For example, a patient undergoing laparoscopic cholecystectomy with controlled pain by day 3 could be prompted to return unused codeine to a pharmacy, whereas a patient after tonsillectomy with escalating pain could receive specialist advice before seeking unscheduled primary care.