Doctors are changing how they prescribe opioids after surgery because the evidence now overwhelmingly shows that most patients simply do not need them — and that giving fewer pills does not increase pain. A landmark study published in March 2026 from the University of Rochester Medical Center found that a team-based approach to opioid stewardship achieved a 67% reduction in opioid prescriptions at discharge with no increase in patient-reported pain concerns, and 70% of patients left the hospital with no opioids at all. Nationally, opioid prescription sizes after surgery have dropped 42% since 2013, and new persistent opioid use after surgery has fallen by more than half. For families navigating dementia care, where cognitive vulnerability makes opioid side effects especially dangerous, these shifts carry particular weight.
This transformation did not happen overnight. It has been driven by updated CDC and FDA guidelines, pioneering hospital programs in Michigan and New York, the approval of the first new class of non-opioid pain medication in decades, and a growing body of research identifying who is most at risk for post-surgical dependence. For older adults — particularly those living with dementia or mild cognitive impairment — opioids carry compounded risks including delirium, falls, accelerated cognitive decline, and dangerous drug interactions with medications already managing behavioral symptoms. This article examines the national prescribing trends behind the shift, the specific programs that have proven it works, the non-opioid alternatives gaining ground, what the changes mean for pediatric and older adult patients, and how families and caregivers can advocate for safer post-surgical pain management.
Table of Contents
- How Much Have Post-Surgical Opioid Prescriptions Actually Changed?
- What Programs Have Proven That Fewer Opioids Still Means Adequate Pain Control?
- How Are Federal Guidelines Reshaping Surgical Pain Management?
- What Non-Opioid Alternatives Are Surgeons Turning To Instead?
- Who Is Most at Risk for Post-Surgical Opioid Dependence?
- How Are Pediatric Guidelines Changing and What Does That Signal for Older Adults?
- Where Is Post-Surgical Pain Management Headed?
- Conclusion
- Frequently Asked Questions
How Much Have Post-Surgical Opioid Prescriptions Actually Changed?
The numbers tell a striking story. A study of nearly one million opioid-naive patients published in the Annals of Surgery in March 2025 found that average opioid prescription sizes after surgery dropped from 282 mg oral morphine equivalents to 164 mg OME between 2013 and 2021 — a 42% reduction. Over that same period, opioid prescription refills within 30 days of surgery fell from 24.6% to 13.6%, an 11 percentage-point decline. Most importantly, new persistent opioid use — patients still taking opioids months after their procedure — dropped from 2.7% to 1.1%. To put that in practical terms, the average patient undergoing a common elective surgery in 2021 received roughly half as many opioid pills as a similar patient in 2013, was far less likely to call back asking for more, and was significantly less likely to develop a lasting dependence. These are not marginal improvements.
They represent a fundamental change in how surgical teams think about post-operative pain. The old default — writing a generous prescription “just in case” — has been replaced by a more deliberate approach: prescribe the minimum effective amount, or in many cases, prescribe no opioids at all. For families dealing with dementia, this shift is especially meaningful. Opioids can cause confusion, sedation, and delirium even in cognitively healthy adults. In someone already experiencing memory loss or disorientation, these effects can be devastating and sometimes irreversible. A shorter, smaller prescription — or none at all — reduces the window of vulnerability.
What Programs Have Proven That Fewer Opioids Still Means Adequate Pain Control?
Two programs stand out as models for how hospitals can reduce opioid prescribing without compromising patient care. Michigan’s Opioid Prescribing Engagement Network, known as MI-OPEN, developed procedure-specific prescribing guidelines covering roughly 25 common operations across more than 70 hospitals statewide. The results have been remarkable: prescription sizes were reduced by 76% with no change in patient-reported pain or satisfaction. New persistent opioid use in Michigan dropped from 3.29% to 2.51% following guideline release. The University of Rochester Medical Center took a different but complementary approach. Their team-based opioid stewardship program, described as the first low-cost, scalable, self-sustaining program spanning all perioperative phases, followed 6,619 opioid-naive adult patients undergoing 15 elective procedures across multiple surgical divisions. Patients discharged with an opioid prescription received an average of 8 fewer pills than before the intervention, and 70% left with no opioids at all.
The key finding: no increase in patient-reported pain concerns. However, it is worth noting a limitation. Both programs focused primarily on elective surgeries in otherwise healthy, opioid-naive adults. Patients with chronic pain conditions, those already on opioid therapy, or those undergoing emergency surgery may have different needs. For older adults with dementia who require surgery — a hip fracture repair, for instance — the calculus is more complex. Pain that goes untreated or undertreated in dementia patients can manifest as agitation, aggression, or withdrawal, symptoms that may be mistakenly attributed to the disease itself rather than to unmanaged pain. The goal is not zero opioids for every patient. It is the right amount of the right medication for the right patient, with careful monitoring.
How Are Federal Guidelines Reshaping Surgical Pain Management?
The regulatory framework around opioid prescribing has shifted substantially in recent years, and these changes have given hospitals both the evidence base and the institutional cover to prescribe less. The 2022 CDC Clinical Practice Guideline — the most current version — states plainly that nonopioid therapies are “at least as effective as opioids for many common types of acute pain, including pain related to minor surgeries.” That language matters. It gives surgeons and anesthesiologists explicit permission to reach for acetaminophen and ibuprofen before reaching for oxycodone. The FDA has also updated prescribing information for all opioid pain medicines, noting that many acute post-surgical pain conditions “require no more than a few days” of immediate-release opioids. Meanwhile, expert consensus guidelines now recommend that the minimum number of opioid tablets to prescribe is zero for many procedures, with a maximum not exceeding 20 tablets for any common operation.
Compare that to a decade ago, when patients routinely left the hospital with 30, 40, or even 60 tablets after procedures like gallbladder removal or knee arthroscopy. For caregivers of people with dementia, these guidelines provide a concrete framework for conversations with surgical teams. If a loved one with cognitive impairment needs surgery, you can reference the CDC guideline and ask specifically whether non-opioid pain management is feasible. You can ask how many pills are being prescribed and why, and whether the surgeon is following procedure-specific guidelines. The existence of these federal recommendations transforms what might feel like a confrontational question into a reasonable, evidence-based inquiry.
What Non-Opioid Alternatives Are Surgeons Turning To Instead?
The shift away from opioids has been made possible in part by a growing menu of alternatives. Multimodal pain protocols — which combine several different types of non-opioid medications — have become the standard of care at leading surgical centers. The typical approach now emphasizes scheduled acetaminophen and NSAIDs as first-line treatment, with opioids reserved strictly for breakthrough pain that other medications cannot control. A genuinely new option arrived in January 2025 with the FDA approval of suzetrigine, sold under the brand name Journavx. This is the first new class of pain medication in decades, targeting the sodium channel NaV1.8 without causing sedation or euphoria — the two properties of opioids that make them both cognitively dangerous and potentially addictive. For dementia patients, the absence of sedation is a critical advantage.
Traditional opioids can push a person with mild cognitive impairment into a delirious state that may take days or weeks to resolve. A pain medication that works through a completely different mechanism and does not cloud thinking represents a meaningful advancement, though long-term data on its use in older adults with cognitive impairment is still being gathered. The research pipeline is active. As of June 2025, there were 26 ongoing opioid-free anesthesia trials registered on ClinicalTrials.gov, exploring whether entire surgical procedures can be managed without opioids at any stage. The tradeoff is that multimodal approaches require more coordination — multiple medications on different schedules, careful attention to kidney function for NSAIDs, liver function for acetaminophen — but the cognitive safety profile is substantially better than opioid-based regimens. For families managing a loved one’s dementia medications alongside post-surgical pain control, this complexity is worth the effort.
Who Is Most at Risk for Post-Surgical Opioid Dependence?
Not all patients face equal risk, and understanding the specific predictors of chronic opioid use after surgery is essential for families and caregivers who need to advocate effectively. Research published in February 2026 identified four key predictors of chronic opioid use post-surgery: Medicaid enrollment, preoperative benzodiazepine use, mood disorders, and anxiety. Each of these risk factors is more prevalent among older adults and, notably, among people living with or caring for someone with dementia. Benzodiazepine use is particularly worth flagging. Medications like lorazepam and diazepam are sometimes prescribed to manage anxiety or agitation in dementia patients, and their concurrent use with opioids dramatically increases the risk of respiratory depression, falls, and cognitive deterioration.
If a person with dementia is already taking a benzodiazepine and then receives an opioid prescription after surgery, the danger compounds rapidly. Caregivers should make sure every member of the surgical team is aware of all current medications, including those prescribed by neurologists or psychiatrists managing the dementia itself. The pediatric data offers a different warning that nonetheless resonates with caregiving families. Research from July 2024 found that 1 in 6 youths filled an opioid prescription before surgery, and 3% were still filling prescriptions 3 to 6 months afterward. While younger patients are a different population than elderly dementia patients, the underlying lesson is the same: the surgical system has historically been too casual about sending patients home with opioids, and some patients — across all age groups — are more vulnerable to lasting harm than others.
How Are Pediatric Guidelines Changing and What Does That Signal for Older Adults?
The American College of Surgeons updated its pediatric post-surgical pain guide in November 2025, emphasizing non-opioid pain control as the first approach, mandating safe disposal of unused opioids, and stating that opioids should never be used as monotherapy in children. While these guidelines target young patients, they signal a broader philosophical shift that affects care across the lifespan. The emphasis on safe disposal of unused opioids is particularly relevant for households where a person with dementia lives.
Leftover pills in a medicine cabinet pose a real ingestion risk for someone with impaired judgment or confusion. If opioids are prescribed after a surgery — for any family member — they should be stored in a locked location and disposed of promptly when no longer needed. Many pharmacies now offer drug take-back programs, and the FDA has approved in-home disposal products that deactivate opioid medications.
Where Is Post-Surgical Pain Management Headed?
The trajectory is clear, but the work is far from finished. Opioid-related fatalities dropped from approximately 83,140 in 2023 to roughly 54,743 in 2024, a significant decline that reflects both prescribing changes and expanded access to naloxone and treatment. Yet despite this progress, new opioid prescriptions are still projected to cause 3.3 million new opioid use disorder cases, 110,000 overdose deaths, and $890 billion in costs over the next 15 years, according to research published in The Lancet Regional Health – Americas.
For the dementia care community, the future likely holds more tailored protocols. As procedure-specific guidelines become standard — rather than one-size-fits-all prescribing — there is growing recognition that older adults with cognitive impairment need their own evidence-based pathways. The approval of suzetrigine and the 26 ongoing opioid-free anesthesia trials suggest that within the next several years, fully opioid-free surgical recovery may become routine for many common procedures. Until then, the most powerful tool available to families is informed advocacy: knowing that the guidelines have changed, that alternatives exist, and that asking for fewer opioids is not asking for more pain.
Conclusion
The way doctors prescribe opioids after surgery has fundamentally changed, driven by large-scale evidence showing that smaller prescriptions — or no opioids at all — do not compromise pain control. National data shows a 42% reduction in prescription sizes, programs like MI-OPEN and the University of Rochester have demonstrated 67-76% reductions in opioid prescribing without increasing pain, and new alternatives like suzetrigine offer pain relief without the cognitive risks that make opioids especially dangerous for people with dementia or other forms of cognitive impairment.
For caregivers and families navigating the intersection of surgical recovery and brain health, these changes are an opportunity and a responsibility. Before any surgery, ask the care team specifically about non-opioid pain management options, ensure they know about all current medications including benzodiazepines and dementia treatments, and request the smallest effective prescription if opioids are deemed necessary. The guidelines are on your side, the evidence supports the ask, and your loved one’s cognitive safety may depend on it.
Frequently Asked Questions
Can surgery be done without any opioids at all?
For many common procedures, yes. The University of Rochester study found that 70% of patients were discharged with no opioids after elective surgery, and 26 clinical trials are currently investigating fully opioid-free anesthesia protocols. However, more complex or painful procedures may still require short courses of opioids for adequate pain control.
What is suzetrigine (Journavx), and is it safe for people with dementia?
Suzetrigine is a new pain medication approved in January 2025 that targets sodium channel NaV1.8 and does not cause the sedation or euphoria associated with opioids. While it avoids the cognitive side effects of traditional opioids, long-term safety data specifically in older adults with dementia is still limited. Discuss its use with the surgical team and neurologist together.
How many opioid pills should be prescribed after common surgeries?
Expert consensus guidelines state that the minimum recommended prescription is zero tablets for many procedures, and no common operation should require more than 20 tablets. If a surgeon prescribes significantly more than this, it is reasonable to ask why.
What should I do with leftover opioid pills after a family member’s surgery?
Dispose of them promptly. This is critical in homes where someone with dementia lives, as unused pills pose an ingestion risk for a person with impaired judgment. Use pharmacy take-back programs or FDA-approved in-home disposal products. Do not leave unused opioids in accessible locations.
Does reducing opioids mean patients will be in more pain?
The evidence consistently says no. Michigan’s OPEN program reduced prescription sizes by 76% with no change in patient-reported pain or satisfaction. The University of Rochester achieved a 67% reduction with no increase in pain concerns. Multimodal approaches using acetaminophen, NSAIDs, and nerve blocks are effective for most surgical pain.
Are older adults with dementia at higher risk from post-surgical opioids?
Yes. Opioids can cause delirium, increased confusion, sedation, falls, and respiratory depression in older adults, and these risks are amplified in people with existing cognitive impairment. Concurrent use of benzodiazepines — sometimes prescribed for dementia-related anxiety — further compounds the danger.
