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Cleveland Clinic program reveals room to reduce opioid prescriptions after breast surgery
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A Cleveland Clinic program reduced the volume of opioids prescribed to patients who underwent breast surgery, according to study results presented during American Society of Breast Surgeons Annual Meeting.
“Prescribed narcotics add to today’s crisis,” Stephanie Valente, DO, FACS, director of the Breast Surgery Fellowship Program and assistant professor of surgery at Cleveland Clinic, said in a press release. “Overprescribed drugs can contribute to a problem for patients. Unused pills can also make their way into the general population. As physicians, we have an obligation to ensure opioids are not prescribed unnecessarily, but that postoperative pain is appropriately controlled. This prospective quality initiative study provided our breast surgeons the information to do so.”
Valente and colleagues reviewed opioid prescriptions for 100 patients who underwent breast surgery at Cleveland Clinic during a 1-month-period in 2017. After implementation of a surgeon education program that aimed to reduce the amount of opioids prescribed, researchers collected data on new prescription regimens and surveyed patients to assess the number of pills taken vs. prescribed.
Results showed the median number of pills taken after excisional biopsy/lumpectomy, mastectomy and mastectomy with reconstruction was significantly lower than the number prescribed, and that 40% of patients reported no postoperative opioid use.
HemOnc Today spoke with Valente about the study and the implications of the findings.
Question: What was the rationale for this study?
Answer: The opioid epidemic across the country has been a critical focus, especially in health care. As surgeons, we treat postoperative pain by prescribing narcotics, thus, we are potentially contributing to the epidemic.
Q: How did you conduct the study?
A: We looked at 100 consecutive patients who underwent breast surgery at our institution. We focused on patients who underwent lumpectomy or excisional biopsy, mastectomy, or mastectomy with reconstruction, and collected data on how many pills we had prescribed for each patient. From this, we came up with a median number of pills that were being prescribed for the different surgeries. We decided that based upon the median, a new goal of number of narcotics would be implemented: 10 pills for lumpectomy, 20 pills for mastectomy and 25 pills for mastectomy with reconstruction. We rolled out this new protocol and conducted surgeon education, including maximizing pain management with ice, Tylenol and use of intraoperative local anesthetics. We allowed for a 3-month to 4-month implementation period, and prospectively collected data on 100 patients to see if the surgeons were meeting the standards that we had set. We also asked our patients postoperatively how many narcotics they took of the ones that they were prescribed.
Q: What did you find?
A: Surgeons adhered to the guidelines that we set, and patients were taking significantly fewer opioids than we prescribed. Our excisional biopsy lumpectomy group took on average one pill, our mastectomy group took about three pills, and our mastectomy with reconstruction group took an average of 18 pills. About 40% of our patients reported taking no narcotics after surgery, but instead managed pain with ibuprofen, Tylenol and ice.
Q: What is the clinical importance of reducing opioid use in this setting specifically?
A: If we reduce the number of narcotics prescribed, we reduce the amount of narcotics that could be abused or misused in the community. We are overprescribing medication that people do not need.
Q: How have these findings changed your institution’s approach?
A: It was a good for surgeons to realize that patients do not require as many narcotics as we originally thought. Also, patient feedback plays a big role in understanding postoperative pain needs. Based upon their feedback, we could decrease our recommendations to five pills for lumpectomy, 10 pills for a mastectomy and 20 pills for mastectomy plus reconstruction. This program is very easily reproducible. The results of the study are applicable to all breast surgeons.
Q: Is this becoming a trend across institutions?
A: It is. States are starting to make recommendations to prescribing boards. The Society for Surgical Oncology surveyed its members about prescribing practices. Patients are interested in alternatives, and surgeons are stepping up to the plate and helping drive this change.
Q: Do you have plans for additional research on this?
A: Yes. Interestingly, 40% of our patients did not take any pain medicine. We were not able to tease out what patient populations might require more or less, so looking at that in future research is a good idea. Honing in on what those 40% of patients did as an alternative to taking pain medicine is important to know. Our next step is to determine if there are patients for whom we can create a narcotic-free plan. – by Jennifer Southall
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For more information:
Stephanie Valente, DO, FACS, can be reached at Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195.
Disclosure: Valente reports no relevant financial disclosures.