Top

Published in:

01-11-2020 | Breast Surgery | Breast Oncology

Adoption of Opioid-Sparing and Non-Opioid Regimens After Breast Surgery in a Large, Integrated Health Care Delivery System

Authors: Avani R. Patel, MBBS, Brooke Vuong, MD, MHA, Gillian E. Kuehner, MD, Patience Odele, MD, Garner Low, PharmD, Alison Savitz, MD, Veronica Shim, MD, Margaret Mentakis, MD, Elizabeth Linehan, MD, Sharon B. Chang, MD, The Permanente Medical Group Breast Research Collaborative

Published in: Annals of Surgical Oncology | Issue 12/2020

Abstract

Background

Postoperative prescriptions have contributed to the opioid epidemic. In response, a large, integrated health care delivery system implemented initiatives to reduce outpatient opioid prescriptions. We evaluated the impact of these interventions on opioid-prescribing practices after breast surgery.

Methods

We examined postoperative prescribing practices before and after the 2016–2018 intervention period. Primary endpoints were the use of non-opioid regimens (NORs) and morphine milligram equivalents (MMEs) prescribed for postoperative pain management, while secondary endpoints were emergency department (ED) visits and readmissions within 7 days of surgery.

Results

In a survey of breast surgeons, 23% reported using NORs in 2017 versus 79% in 2019 (p < 0.001). Comparing 1917 breast operations from 2016 with 2166 operations from 2019, NORs increased from 9% in 2016 to 39% in 2019 (p < 0.001). Average discharge MMEs per operation decreased from 190 in 2016 to 106 in 2019 (p < 0.001). NOR failure (defined as an additional opioid prescription within 2 weeks of surgery) was < 1%. Significantly fewer postoperative ED visits occurred in the NOR group (1.9% NOR vs. 3.4% opioid regimen [OR]; p < 0.001). The 7-day readmission rates for NOR and OR patients were similar (0.49% NOR vs. 0.32% OR; p = 0.45).

Conclusion

Between 2016 and 2019, breast surgeons in a large, integrated health care delivery system adopted NORs for nearly 40% of breast operations, and prescribed significantly fewer MMEs, with no increases in ED visits or readmissions for NOR patients. This suggests that initiatives to decrease opioid prescribing were successful and that a NOR for pain management after breast surgery is feasible.

Available only for authorised users

Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and opioid-involved overdose deaths. MMWR Morbidity and mortality weekly report 2020;69(11): 290–297. https://doi.org/10.15585/mmwr.mm6911a4CrossRefPubMed

Clark DJ, Schumacher MA. America’s opioid epidemic: supply and demand considerations. Anesth Analg. 2017;125(5):1667-1674. https://doi.org/10.1213/ane.0000000000002388CrossRefPubMed

Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long term analgesic use after low risk surgery. Arch Intern Med. 2012;172(5):425-430. https://doi.org/10.1001/archinternmed.2011.1827CrossRefPubMed

Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-93. https://doi.org/10.1001/jamainternmed.2016.3298CrossRefPubMedPubMedCentral

Barth RJ, Waljee JF (2020) Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a “Never Event”. JAMA Surg, https://doi.org/10.1001/jamasurg.2020.0432CrossRefPubMed

Overton HN, Hanna MN, Bruhn WE, Hutfless S, Bicket MC, Makary MA. Opioids After Surgery Workgroup. Opioid-prescribing guidelines for common surgical procedures: an expert panel consensus. J Am Coll Surg, 2018;227(4):411-418. https://doi.org/10.1016/j.jamcollsurg.2018.07.659CrossRefPubMedPubMedCentral

Chou R, Gordon DB, Leon-Casasola OAD, et al. Management of postoperative pain: a clinical practice guideline from the American pain society, the American society of regional anesthesia and pain medicine, and the American society of anesthesiologists committee on regional anesthesia, executive committee, and administrative council. J Pain. 2016;17(2):131-57. https://doi.org/10.1016/j.jpain.2015.12.008CrossRefPubMed

Rao R, Jackson RS, Rosen B, et al. Pain control in breast surgery: survey of current practice and recommendations for optimizing management—American society of breast surgeons opioid/pain control workgroup. Ann Surg Oncol. 2020;27(4):985-990. https://doi.org/10.1245/s10434-020-08197-zCrossRefPubMed

Gordon NP. Similarity of the adult Kaiser Permanente membership in Northern California to the insured and general population in northern California: statistics from the 2011 California health interview survey. [Internet] Oakland, CA: Kaiser Permanente Division of Research; 2015. Jun 19, [cited 2015 Nov 11]. Available from: https://divisionofresearch.kaiserpermanente.org/projects/memberhealthsurvey/SiteCollectionDocuments/chis_non_kp_2011.pdf

10.

Liu VX, Rosas E, Hwang J, et al. Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg. 2017;152(7):e171032. https://doi.org/10.1001/jamasurg.2017.1032CrossRefPubMedPubMedCentral

11.

Liu VX, Eaton A, Lee DC, et al. Postoperative opioid use before and after enhanced recovery after surgery program implementation. Ann Surg. 2019; 270(6):e69-e71. https://doi.org/10.1097/sla.0000000000003409CrossRefPubMedPubMedCentral

12.

Rothenberg KA, Huyser MR, Edquilang JK, et al. Experience with a nonopioid protocol in ambulatory breast surgery: opioids are rarely necessary and use is surgeon-dependent. Perm J. 2019;23:18-127. https://doi.org/10.7812/tpp/18-127CrossRefPubMedPubMedCentral

13.

Rojas KE, Manasseh DM, Flom PL, et al. A pilot study of a breast surgery enhanced recovery after surgery (ERAS) protocol to eliminate narcotic prescription at discharge. Breast Cancer Res Treat. 2018;171(3):621-626. https://doi.org/10.1007/s10549-018-4859-yCrossRefPubMed

14.

Hartford LB, Van Koughnett JAM, Murphy PB, et al. The standardization of outpatient procedure (STOP) narcotics: a prospective health systems intervention to reduce opioid use in ambulatory breast surgery. Ann Surg Oncol. 2019; 26(10):3295-3304. https://doi.org/10.1245/s10434-019-07539-w.CrossRefPubMed

15.

Gee KM, Jones RE, Nevarez N, Mcclain LE, Wools G, Beres AL. No pain is gain: a prospective evaluation of strict non-opioid pain control after pediatric appendectomy. J Pediatr Surg. 2020;55(6):1043–1047. https://doi.org/10.1016/j.jpedsurg.2020.02.051CrossRefPubMed

16.

Weinheimer K, Michelotti B, Silver J, Taylor K, Payatakes A. A prospective, randomized, double-blinded controlled trial comparing ibuprofen and acetaminophen versus hydrocodone and acetaminophen for soft tissue hand procedures. J Hand Surg Am. 2019;44(5):387-393. https://doi.org/10.1016/j.jhsa.2018.10.014CrossRefPubMed

17.

Sim V, Hawkins S, Gave AA, et al. How low can you go: achieving postoperative outpatient pain control without opioids. J Trauma Acute Care Surg. 2019;87(1):100-103. https://doi.org/10.1097/ta.0000000000002295CrossRefPubMed

18.

Carrier CS, Garvey KD, Brook EM, Matzkin EG. Patient satisfaction with nonopioid pain management following knee arthroscopic partial meniscectomy and/or chondroplasty. Orthopedics. 2018;41(4):209-214. https://doi.org/10.3928/01477447-20180613-02CrossRefPubMed

19.

Papoian V, Handy KG, Villano AM, et al. Randomized control trial of opioid- versus nonopioid-based analgesia after thyroidectomy. Surgery. 2020;167(6):957–961. https://doi.org/10.1016/j.surg.2020.01.011CrossRefPubMed

20.

Kennedy GT, Hill CM, Huang Y, et al. Enhanced recovery after surgery (ERAS) protocol reduces perioperative narcotic requirement and length of stay in patients undergoing mastectomy with implant-based reconstruction. Am J Surg. 2020;220(1):147–152. https://doi.org/10.1016/j.amjsurg.2019.10.007.07CrossRefPubMed

21.

Rendon JL, Hodson T, Skoracki RJ, Humeidan M, Chao AH. Enhanced recovery after surgery protocols decrease outpatient opioid use in patients undergoing abdominally based microsurgical breast reconstruction. Plast Reconstr Surg. 2020; 145(3):645-651. https://doi.org/10.1097/prs.0000000000006546CrossRefPubMed

22.

Morrow M, Jagsi R, McLeod MC, Shumway D, Katz SJ. Surgeon attitudes toward the omission of axillary dissection in early breast cancer. JAMA Oncol. 2018; 4(11): 1511-1516. https://doi.org/10.1001/jamaoncol.2018.1908CrossRefPubMedPubMedCentral

23.

Vuong B, Graff-Baker AN, Yanagisawa M, et al. Implementation of a post-mastectomy home recovery program in a large, integrated health care delivery system. Ann Surg Oncol. 2019;26(10):3178-3184. https://doi.org/10.1245/s10434-019-07551-0CrossRefPubMed

24.

Sada A, Thiels CA, Britain MK, Dudakovic A, et al. Optimizing discharge opioid prescribing practices after mastectomy with immediate reconstruction. Mayo Clin Proc Innov Qual Outcomes. 2019;3(2):183-188. https://doi.org/10.1016/j.mayocpiqo.2019.03.001CrossRefPubMedPubMedCentral

25.

Fan B, Valente SA, Shilad S, et al. Reducing narcotic prescriptions in breast surgery: a prospective analysis. Ann Surg Oncol. 2019;26(10):3109-3114. https://doi.org/10.1245/s10434-019-07542-1CrossRefPubMed

26.

Hart AM, Broecker JS, Kao L, Losken A. Opioid use following outpatient breast surgery: are physicians part of the problem? Plast Reconstr Surg. 2018;142(3):611-620. https://doi.org/10.1097/prs.0000000000004636CrossRefPubMed

Title: Adoption of Opioid-Sparing and Non-Opioid Regimens After Breast Surgery in a Large, Integrated Health Care Delivery System
Authors: Avani R. Patel, MBBS
Brooke Vuong, MD, MHA
Gillian E. Kuehner, MD
Patience Odele, MD
Garner Low, PharmD
Alison Savitz, MD
Veronica Shim, MD
Margaret Mentakis, MD
Elizabeth Linehan, MD
Sharon B. Chang, MD
The Permanente Medical Group Breast Research Collaborative
Publication date: 01-11-2020
Publisher: Springer International Publishing
Keywords: Breast Surgery
Postoperative Pain Management
Mastectomy
Breast Surgery
Opioids
Opioids
Care
Published in: Annals of Surgical Oncology / Issue 12/2020
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-020-08897-6

At a glance: The STEP trials

Springer Medicine

Adoption of Opioid-Sparing and Non-Opioid Regimens After Breast Surgery in a Large, Integrated Health Care Delivery System

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 12/2020

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel—The American Society of Breast Surgeons

Factors Associated with Pathological Node Negativity in Inflammatory Breast Cancer: Are There Patients Who May be Candidates for a De-Escalation of Axillary Surgery?

Do Nipple Necrosis Rates Differ in Prepectoral Versus Submuscular Implant-Based Reconstruction After Nipple-Sparing Mastectomy?

Breast Reconstruction in the Setting of Stage 4 Breast Cancer: Is It Worthwhile?

Impact of Phone-Call and Access-Enhancing Intervention on Mammography Uptake among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Controlled Study

Obese Patients Who Receive an Opioid-Sparing Enhanced Recovery After Surgery (ERAS) Protocol are at Increased Risk of Persistent Pain After Breast Surgery