Download Request for Pain Clinic Provider Clearance

Mailing Address:
Division of Gastrointestinal & Bariatric Surgery
420 Delaware Street SE, MMC 195
Minneapolis, MN 55455
Office: 612-626-6666
Fax: 612-625-3206
Dear Pain Clinic Provider:
Thank you for taking the time to see our mutual patient for clearance from a pain
management perspective prior to bariatric surgery. Please assist us with the following
during your evaluation of our mutual patient:
•
Provide a letter stating that the patient is cleared to proceed with bariatric surgery
from a pain management standpoint.
•
Provide any recommendations for pre-surgery (if any), and after surgery (if it
varies from our protocol below).
•
Guide and facilitate follow-up treatment beyond the 30 days post op period.
If you have any questions, contact Barbara Sampson, RN, Nurse Coordinator, at phone
#: 612-625-1124 or pager: 612-899-1106. Please fax the letter to 612-625-3206.
Sincerely,
Dr. Sayeed Ikramuddin; Dr. Daniel Leslie; Kristi Kopacz, PA-C
Weight Loss Surgery Center
University of Minnesota HEALTH
www.umnwls.org
Weight Loss Surgery Pain Medication Protocol:
1. After Bariatric surgery patients will generally be sent home with a prescription for
Roxicet elixir 150-200 cc (equivalent to 30-40 Percocet).
2. Primary laparoscopic bariatric surgery patients should expect to require narcotic pain
meds for a few days to a week. After the first few days pain medications can be
decreased and transitioned to Tylenol if needed. No non-steroidal medications such as
ibuprofen, naproxen, Motrin, Aleve, Advil etc. should be used.
3. We do not prescribe pain medications beyond 30 days post op for standard post-op
pain.
4. If a pain medication refill is needed, a clinic visit will be required. Narcotic
prescriptions cannot be called into pharmacies.
5. If patient requires pain medication before surgery they will need to have a clear plan
from their pain treating provider for pain management after their surgery. We will ask
that their provider manage all narcotic pain prescriptions after the immediate post op
period.