The Standardization of Outpatient Procedure (STOP) Narcotics: A Prospective Health Systems Intervention to Reduce Opioid Use in Ambulatory Breast Surgery

Abstract

Background

During the past 15 years, opioid-related overdose death rates for women have increased 471%. Many surgeons provide opioid prescriptions well in excess of what patients actually use. This study assessed a health systems intervention to control pain adequately while reducing opioid prescriptions in ambulatory breast surgery.

Methods

This prospective non-inferiority study included women 18–75 years of age undergoing elective ambulatory general surgical breast procedures. Pre- and postintervention groups were compared, separated by implementation of a multi-pronged, opioid-sparing strategy consisting of patient education, health care provider education and perioperative multimodal analgesic strategies. The primary outcome was average pain during the first 7 postoperative days on a numeric rating scale of 0–10. The secondary outcomes included medication use and prescription renewals.

Results

The average pain during the first 7 postoperative days was non-inferior in the postintervention group despite a significant decrease in median oral morphine equivalents (OMEs) prescribed (2.0/10 [100 OMEs] pre-intervention vs 2.1/10 [50 OMEs] post-intervention; p = 0.40 [p < 0.001]). Only 39 (44%) of the 88 patients in the post-intervention group filled their rescue opioid prescription, and 8 (9%) of the 88 patients reported needing an opioid for additional pain not controlled with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) postoperatively. Prescription renewals did not change.

Conclusion

A standardized pain care bundle was effective in minimizing and even eliminating opioid use after elective ambulatory breast surgery while adequately controlling postoperative pain. The Standardization of Outpatient Procedure Narcotics (STOP Narcotics) initiative decreases unnecessary and unused opioid medication and may decrease risk of persistent opioid use. This initiative provides a framework for future analgesia guidelines in ambulatory breast surgery.

Appendices

Appendix 1: Multi-pronged Opioid-Sparing Intervention

Patient Education

Patients were educated by staff, residents, and nurses through written instructions (standardized education sheets) and verbal reinforcement on two occasions: the initial surgical consultation and the day of surgery. Patients’ expectations surrounding the surgery, discomfort, and the recovery process were clarified. Instructions focused on optimal use of non-opioid analgesic medications (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) and conservative measures such as ice therapy. Patients were instructed only to fill a separate rescue 10-tablet opioid prescription if their discomfort was not satisfactorily controlled by other measures. Finally, patients were educated on appropriate medication disposal.

Provider Education

Surgeons, anesthetists, residents, post-anesthesia care unit (PACU) nurses and pre-admission clinic (PAC) staff were educated through divisional rounds, meetings, and emails. This education focused on current evidence surrounding opioid use and prescribing after surgery, as well as the development and commencement of the Standardization of Outpatient Procedure Narcotics (STOP Narcotics) initiative.

Intraoperative Protocol

Concerning the surgical safety checklist, it was reinforced with the anesthetist that patients were to receive ketorolac (15–30 mg IV), ondansetron (4–8 mg IV), and dexamethasone (4–8 mg IV) during the surgery. All surgeons were encouraged to use local anesthetic field blocks (lidocaine or bupivacaine).

Postoperative Protocol

Patients received a prescription for an NSAID (meloxicam 7.5 mg or naproxen 400 mg) to be taken twice daily for 72 h. Acetaminophen 500 mg also was to be taken every 6 h for 72 h. After 72 h, patients were instructed to take ibuprofen 400 mg and acetaminophen 500 mg as needed. A separate rescue prescription of 10 tablets of an opioid prescription was provided (tramadol 50 mg or codeine 30 mg). This prescription expired in 7 days, with instructions to fill it only if discomfort was not sufficiently achieved through other analgesic and conservative measures. Ice therapy also was used at the discretion of the surgeon and patient.

Appendix 2: Postoperative Pain Management Instructions

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.

Ice therapy was suggested to help reduce swelling and discomfort at the surgical site during the acute postoperative period. Patients were instructed that an ice pack wrapped in a cloth may be applied to the breast and/or axilla for the first couple of days after surgery. This was recommended for 15 min/15 min off at a time.

First 3 days (72 h) After Surgery

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

• 2. Acetaminophen 500 mg; 1–2 tablets PO q6 h, for 3 days.

If the patient does not have coverage for meloxicam, the following may be prescribed:

• 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. Continue acetaminophen 500 mg: 1–2 tablets PO q6 h as needed

• 2. Ibuprofen 400 mg; 1 tablet PO q6 h as needed.

Patients are given separate prescriptions with the following instructions:

Tramadol 50 mg: 1 tablet PO q6 h PRN (10 tabs) (expiration date 7 days)

If the patient does not have coverage for tramadol, the following may be prescribed:

Codeine 30 mg: 1 tab PO q6 h PRN (10 tablets) (expiration date 7 days)

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