Skip to main content

Advertisement

SpringerLink
Log in

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

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. 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.mm6911a4

    Article  PubMed  Google Scholar 

  2. 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.0000000000002388

    Article  PubMed  Google Scholar 

  3. 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.2011.1827

    Article  PubMed  Google Scholar 

  4. 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.2016.3298

    Article  PubMed  PubMed Central  Google Scholar 

  5. 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.2020.0432

    Article  PubMed  Google Scholar 

  6. 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.2018.07.659

    Article  PubMed  PubMed Central  Google Scholar 

  7. 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.2015.12.008

    Article  PubMed  Google Scholar 

  8. 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-z

    Article  PubMed  Google Scholar 

  9. 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.2017.1032

    Article  PubMed  PubMed Central  Google Scholar 

  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.0000000000003409

    Article  PubMed  PubMed Central  Google Scholar 

  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/18-127

    Article  PubMed  PubMed Central  Google Scholar 

  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-y

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.2020.02.051

    Article  PubMed  Google Scholar 

  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.2018.10.014

    Article  PubMed  Google Scholar 

  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.0000000000002295

    Article  CAS  PubMed  Google Scholar 

  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/10.3928/01477447-20180613-02

    Article  PubMed  Google Scholar 

  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.2020.01.011

    Article  PubMed  Google Scholar 

  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.2019.10.007.07

    Article  PubMed  Google Scholar 

  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.0000000000006546

    Article  CAS  PubMed  Google Scholar 

  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.2018.1908

    Article  PubMed  PubMed Central  Google Scholar 

  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/s10434-019-07551-0

    Article  PubMed  Google Scholar 

  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.2019.03.001

    Article  PubMed  PubMed Central  Google Scholar 

  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/s10434-019-07542-1

    Article  PubMed  Google Scholar 

  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.0000000000004636

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgment

The authors thank the Kaiser Permanente Enhanced Recovery™ team for editorial input.

Author information

Authors and Affiliations

  1. Department of Surgery, Kaiser Permanente Fremont Medical Center, Fremont, CA, USA

    Avani R. Patel MBBS & Sharon B. Chang MD

  2. Department of Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA

    Brooke Vuong MD, MHA & Margaret Mentakis MD

  3. Department of Surgery, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, USA

    Gillian E. Kuehner MD

  4. Department of Surgery, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA

    Patience Odele MD

  5. Pharmacy Drug Use Management, Kaiser Permanente Northern California, Oakland, CA, USA

    Garner Low PharmD

  6. Department of Surgery, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA

    Alison Savitz MD

  7. Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA

    Veronica Shim MD

  8. Department of Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA

    Elizabeth Linehan MD

Authors
  1. Avani R. Patel MBBS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brooke Vuong MD, MHA
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gillian E. Kuehner MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Patience Odele MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Garner Low PharmD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Alison Savitz MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Veronica Shim MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Margaret Mentakis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Elizabeth Linehan MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Sharon B. Chang MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

The Permanente Medical Group Breast Research Collaborative

Corresponding author

Correspondence to Sharon B. Chang MD.

Ethics declarations

Disclosures

Avani R. Patel, Brooke Vuong, Gillian E. Kuehner, Patience Odele, Garner Low, Alison Savitz, Veronica Shim, Margaret Mentakis, Elizabeth Linehan, and Sharon B. Chang have no disclosures to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 55 kb)

Appendix 1: Kaiser Permanente Enhanced Recovery™ Perioperative Multimodal Analgesia Regimens

Appendix 1: Kaiser Permanente Enhanced Recovery™ Perioperative Multimodal Analgesia Regimens

  • Provide as many modalities as appropriate from the list below, except where contraindicated.

  • Outpatients: encourage the use of ≥ 2 modalities. For patients not anticipated to need ANY opioid analgesics in PACU, encourage the use of at least 1 modality.

Component

Regimen

Acetaminophen

1 gm IV/PO perioperatively, then Q6H ATC

Gabapentin

300-600 mg PO preoperatively

NSAIDs

Ketorolac 15-30 mg IV perioperatively, then Q6H x 24 h

Ibuprofen 400-600 mg PO Q6H ATC

Celecoxib 100-400 mg PO preoperatively

Peripheral nerve blocks

 

Ketamine

Per anesthesia provider

Dexmedetomidine

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Patel, A.R., Vuong, B., Kuehner, G.E. et al. Adoption of Opioid-Sparing and Non-Opioid Regimens After Breast Surgery in a Large, Integrated Health Care Delivery System. Ann Surg Oncol 27, 4835–4843 (2020). https://doi.org/10.1245/s10434-020-08897-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-020-08897-6

Search

Navigation