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The Standardization of Outpatient Procedure (STOP) Narcotics after anorectal surgery: a prospective non-inferiority study to reduce opioid use

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Abstract

Background

Prescription of opioid medication after ambulatory anorectal surgery may be excessive and lead to opioid misuse. The purpose of this study was to evaluate the efficacy of a multi-modality opioid-sparing approach to control postoperative pain and reduce opioid prescriptions after outpatient anorectal surgery.

Methods

A prospective non-inferiority pre- and post-intervention study was completed at three academic hospitals. Patients included were 18–75 years of age who had outpatient anorectal surgeries. The Standardization of Outpatient Procedure (STOP) Narcotics intervention was implemented, which is a multi-pronged analgesia bundle integrating patient education, health care provider education, and intra-/postoperative analgesia focused on multi-modal pain control strategies and opioid-reduced prescriptions. The primary outcome was patient-reported average pain in the first 7 postoperative days. Secondary outcomes included patient-reported quality of pain management, medication utilization, prescription refills and medication disposal.

Results

Ninety-three patients had outpatient anorectal surgery (42 pre-intervention and 51 post-intervention). No difference was seen in average postoperative pain in the pre- vs. post-intervention groups (2.8 vs. 2.6 on an 11-point scale, p = 0.33) or patient-reported quality of pain control (good/very good in 57% vs. 63%, p = 0.58). The median oral morphine equivalents (OME) prescribed was significantly less [112.5 (IQR 50–150) pre-intervention vs. 50 (IQR 50–50) post-intervention, p < 0.001]. In the post-intervention group, only 45% of patients filled their opioid prescription and median opioid use was 12.5 OME (2.5 pills).

Conclusions

While pain control after anorectal surgery must consider the individual patient’s needs, a standardized pain care bundle significantly decreased opioid prescribing without an increase in patient-reported postoperative pain.

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Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

    L. B. Hartford, P. B. Murphy, D. K. Gray, A. Maciver, L. J. Allen, C. Garcia-Ochoa, K. A. Leslie & J. A. M. Van Koughnett

  2. Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

    C. F. M. Clarke

  3. Division of Surgical Oncology, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

    J. A. M. Van Koughnett

  4. London Health Sciences Centre, University Hospital, Room C8-002, 339 Windermere Road, London, ON, N6A 5A5, Canada

    J. A. M. Van Koughnett

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  1. L. B. Hartford
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Correspondence to J. A. M. Van Koughnett.

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The material was presented at the Annual Scientific Meeting of the American Society of Colon and Rectal Surgeons in June 2019.

Appendix: Postoperative pain management strategy for anorectal surgery

Appendix: Postoperative pain management strategy for anorectal surgery

Patients were asked to notify their surgeon if they had a history of stomach ulcers, liver disease, kidney disease or allergies to any of these medications.

First 3 days (72 h) after surgery:

  1. 1.

    Meloxicam 7.5 mg: 1 tablet PO, q12 hours, for 3 days (prescription).

  2. 2.

    Acetaminophen 500 mg; 1–2 tablets PO q6hours, for 3 days.

If the patient does not have coverage for Meloxicam, you may prescribe the following:

  1. 1.

    Naproxen 200 mg (Aleve): Take 2 tablets orally, every 12 h, for 3 days.

To maximize pain relief, it was strongly recommended to take both of these medications.

After 3 days (72 h) after surgery:

  1. 1.

    Continue Acetaminophen 500 mg: 1–2 tablets PO q6hours PRN.

  2. 2.

    Ibuprofen 400 mg; 1 tablet PO q6hours PRN.

Patients are given separate prescriptions with the following instructions:

Tramadol 50 mg: 1 tab PO q6hours PRN (10 tabs) (Expiry date 7 days).

If the patient does not have coverage for Tramadol, you may prescribe the following.

Codeine 30 mg: 1 tab PO q6hours PRN (10 tabs) (Expiry date 7 days).

Patients were given instructions to only fill this prescription, if the above measures do not adequately control their pain.

Metronidazole 500 mg: 1 tab PO q12hours for 5 days.

Polyethylene glycol (PEG) 17 g: Take once to twice daily to avoid constipation.

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Hartford, L.B., Murphy, P.B., Gray, D.K. et al. The Standardization of Outpatient Procedure (STOP) Narcotics after anorectal surgery: a prospective non-inferiority study to reduce opioid use. Tech Coloproctol 24, 563–571 (2020). https://doi.org/10.1007/s10151-020-02190-0

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