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Opioid-sparing policy reduces use without increasing pain after surgery
A restrictive protocol safely and effectively reduced the number of opioids prescribed to patients who underwent gynecologic or abdominal surgery, according to findings from a 2-year pilot case-control study.
“Physicians are often concerned that reducing or eliminating opioid prescriptions will be challenging, especially for patients who are accustomed to managing pain with opioids,” Emese Zsiros, MD, PhD, FACOG, assistant professor of oncology in the department of gynecologic oncology at Roswell Park Comprehensive Cancer Center, said in a press release. “However, our study clearly shows that patients can recover from major surgery just as well with over-the-counter pain medications, such as ibuprofen or acetaminophen, and minimal or no opioids, with no increase in pain or postoperative complications — and without the side effects of opioids, such as nausea, constipation, sluggishness and dizziness, as well as the risk for long-term opioid use, abuse and diversion.”
About one in 20 patients prescribed opioids for acute pain will become a chronic user, Zsiros said.
“In my opinion, opioid addiction can be viewed as a significant postoperative complication that clinical teams must work to prevent,” she said.
Zsiros and colleagues initiated their study in June 2017.
Patients who underwent ambulatory or minimally invasive gynecologic surgery were not prescribed opioids at discharge unless they required more than five doses of opioids while in the hospital. Patients who underwent laparotomy received a 3-day supply of opioids (12 pills) at discharge, or 24 pills if they needed more opioids during the last 24 hours of their hospital stay. All patients received a prescription for 600 mg ibuprofen and 500 mg acetaminophen every 6 hours as needed for 7 days unless there was a contraindication, in which case they received a 3-day supply of opioids.
According to study results, the significant reduction in the number of prescribed opioids after surgery did not negatively impact patients’ pain scores, nor did it result in increased postoperative complications or patient requests for more opioids.
In addition, the alternative approach to pain management — including ibuprofen and acetaminophen — appeared safe and effective.
HemOnc Today spoke with Zsiros about the study rationale, the implications of the findings and whether other institutions can implement a similar restrictive protocol.
Question: Can you describe the study rationale?
Answer: About 2 years ago, we realized in the midst of the opioid crisis that we surgeons were over-prescribing opioids to our patients. Most of our laparoscopy or robotic surgery patients stated after surgery that they did not take any opioids or only took a few pills. We decided we needed to find out the true need for opioids in patient recovery and designed a protocol that we thought was appropriate for our patients.
Q: How did you conduct the study?
A: Rather than asking our patients to bring back the pills they did not use, we decided to see how the patients would feel if we did not give them opioids, or if we gave them a very minimal number of pills at discharge. We hypothesized that most of the ambulatory cases and patients who underwent a minimally invasive procedure, such as laparoscopy or robotic surgery, would be fine with no opioids. For the patients who underwent a major open surgery, we as a team felt that giving them an additional 3-day supply of opioids at discharge would be sufficient to control their pain. All patients were educated before surgery about the revised protocol, including what to expect in terms of pain or possible complications. We also encouraged the patients to contact their clinical team with any questions or concerns, especially if their pain was not adequately managed.
Q: Can you elaborate on the findings ?
A: None of our patients called for a refill, and they all came back for their follow-up appointment having recovered very well. We have been doing this for 1.5 years without any changes and more than 600 patients have recovered well, with their pain at the surgical site well-controlled. The opioid refill rate was exactly the same as the prior year, when we had liberal opioid prescriptions. Also, complications after surgery did not increase.
Q: What is the clinical importance of reducing opioid use?
A: The reduction in opioid use promotes optimal healing and recovery. Essentially, zero to minimal opioids is probably sufficient for most surgical patients to recover adequately and comfortably. We know that opioids come with a lot of side effects. In the past, we admitted a lot of patients with small bowel obstruction after surgery, or patients dealt with a lot of constipation as a result of opioid use after surgery. So, by not overprescribing opioids, we minimized the symptoms caused by opioids. Also, studies show that the risk for conversion from an opioid-naive patient to a chronic opioid user is approximately 5% after minor surgery and approximately 6% after major surgery. We should be looking at chronic opioid use as a postoperative complication. Approximately 116 people die every day in the U.S. from an opioid overdose, and 80% of those patients who die started on prescription opioids.
Q: How have these findings changed your institution’s approach?
A: As of Jan. 1, we streamlined our pain-management guidelines across all surgical services, stratified based on what is most effective for different surgical procedures. Some patients go home with no opioids, others with a 1-day supply, and some with a 3-day supply. We also created a preoperative educational video that we show to all surgical patients informing them about the dangers of opioids and the expectations for pain management after surgery.
Q: Is this something that other institutions could/should implement?
A: Very much so. I have talked to third-party payers who are looking at our protocol. We would like to contribute to the effort to design national guidelines and prescribing policies, which currently are not in place. This approach would not be appropriate for all patients with cancer, particularly those dealing with chronic pain from their disease. However, as a guideline or starting point, we believe this can be a very effective and beneficial model. We have a video that we encourage other centers to use, and it is available at www.youtube.com/watch?v=95fBQSCyj3g&feature=youtu.be.
Q: Do you plan to conduct additional research on this topic?
A: We expect to report our experience, looking back to the past 6 to 12 months and extracting data on our surgical patients as a comparison point to investigate how patients behave around surgery. We want to see which patients are converting to chronic opioid users and why. – by Jennifer Southall
Reference:
Mark J, et al. JAMA Netw Open. 2018;doi:10.1001/jamanetworkopen.2018.5452.
For more information:
Emese Zsiros, MD, PhD, FACOG, can be reached at Roswell Park Cancer Institute, Elm and Carlton streets, Buffalo, NY 14263; email: emese.zsiros@roswellpark.org.
Disclosure: Zsiros reports no relevant financial disclosures.