Surgeon perception versus reality: Opioid use after breast cancer surgery

Physician Characteristics Associated With Opioid Prescribing After Same-Day Breast Surgery in Ontario, Canada: A Population-Based Cohort Study

Background and Objectives

Opioid overprescribing in patients undergoing breast surgery is a concern, as evidence suggests that minimal or no opioid is needed to manage pain. We sought to describe characteristics of opioid prescribers and determine associations between prescriber's characteristics and high opioid prescribing within 7 days of same-day breast surgery.

Methods

Patients ≥18 years of age who underwent same-day breast surgery in Ontario, Canada from 2012 to 2020 were identified and linked to prescriber data. The primary outcome was current high opioid prescribing defined as >75th percentile of the mean oral morphine equivalents (OME; milligrams). Prescriber characteristics including age, sex, specialty, years in practice, practice setting, and history of high (>75th percentile) opioid prescribing in the previous year were captured. Associations between prescriber characteristics and the primary outcome were estimated in modified Poisson regression models.

Results

The final cohort contained 56,434 patients, 3469 unique prescribers, and 58,656 prescriptions. Over half (1971/3469; 57%) of prescribers wrote ≥1 prescription that was >75th percentile of mean OME of 180 mg, of which 50% were family practice physicians. Adjusted mean OMEs prescribed varied by specialty with family practice specialties prescribing the highest mean OME (614 ± 38 mg) compared to surgical specialties (general surgery [165 ± 9 mg], plastic surgery [198 ± 10 mg], surgical oncology [154 ± 14 mg]). Whereas 73% of first and 31% of second prescriptions were provided by general surgery physicians, family practice physicians provided 2% of first and 51% of second prescriptions. Prescriber characteristics associated with a higher likelihood of high current opioid prescribing were family practice (risk ratio [RR], 1.56; 95% confidence interval [CI], 1.35-1.79 compared to general surgery), larger community practice setting (RR, 1.34; 95% CI, 1.05-1.71 compared to urban), and a previous high opioid prescribing behavior (RR, 2.28; 95% CI, 2.06-2.52).

Conclusions

While most studies examine surgeon opioid prescribing, our data suggest that other specialties contribute to opioid overprescribing in surgical patients and identify characteristics of physicians likely to overprescribe.

Variation in opioid filling after same-day breast surgery in Ontario, Canada: a population-based cohort study

BACKGROUND

Postoperative pain management practices in breast surgery are variable, with recent evidence that approaches for minimizing or sparing opioids can be successfully implemented. We describe opioid filling and predictors of higher doses in patients undergoing same-day breast surgery in Ontario, Canada.

METHODS

In this retrospective population-based cohort study, we used linked administrative health data to identify patients aged 18 years or older who underwent same-day breast surgery from 2012 to 2020. We categorized procedure types by increasing invasiveness of surgery: partial, with or without axillary intervention (P ± axilla); total, with or without axillary intervention (T ± axilla); radical, with or without axillary intervention (R ± axilla); and bilateral. The primary outcome was filling an opioid prescription within 7 or fewer days after surgery. Secondary outcomes were total oral morphine equivalents (OMEs) filled (mg, median and interquartile range [IQR]) and filling more than 1 prescription within 7 or fewer days after surgery. We estimated associations (adjusted risk ratios [RRs] and 95% confidence intervals [CIs]) between study variables and outcomes in multivariable models. We used a random intercept for each unique prescriber to account for provider-level clustering.

RESULTS

Of the 84 369 patients who underwent same-day breast surgery, 72% (n = 60 620) filled an opioid prescription. Median OMEs filled increased with invasiveness (P ± axilla = 135 [IQR 90-180] mg; T ± axilla = 135 [IQR 100-200] mg; R ± axilla = 150 [IQR 113-225] mg, bilateral surgery = 150 [IQR 113-225] mg; p < 0.0001). Factors associated with filling more than 1 opioid prescription were age 30-59 years (v. age 18-29 yr), increased invasiveness (RR 1.98, 95% CI 1.70-2.30 bilateral v. P ± axilla), Charlson Comorbidity Index ≥ 2 versus 0-1 (RR 1.50, 95% CI 1.34-1.69) and malignancy (RR 1.39, 95% CI 1.26-1.53).

INTERPRETATION

Most patients undergoing same-day breast surgery fill an opioid prescription within 7 days. Efforts are needed to identify patient groups where opioids may be successfully minimized or eliminated.

How to teach ERAS protocols: surgical residents' perspectives and perioperative practices for breast surgery patients

Purpose

Breast enhanced recovery after surgery (ERAS) protocols emphasize multimodal analgesia to expedite home recovery, but variable implementation remains. This study examines how residents learn and use ERAS protocols, how they conceptualize pain management, and what influences breast surgery patients' same-day discharges.

Methods

Interviews were conducted with surgical residents following their breast surgery rotation using an interview guide adapted from existing pain management literature. Interviews were transcribed, de-identified, and independently inductively coded by two researchers. A codebook was developed and refined using the constant comparative method. Codes were grouped into categories and explored for thematic analysis.

Results

Twelve interviews were completed with plastic and general surgery residents. Ultimately, 365 primary codes were organized into 26 parent codes, with a Cohen's kappa of 0.93. A total of six themes were identified. Three themes described how participants learn through a mixture of templated care, formal education, and informal experiential learning. Two themes delineated how residents would teach breast surgery ERAS: by emphasizing buy-in and connecting the impetus behind ERAS with daily workflow implementation. One theme illustrated how a patient-centered culture impacts postoperative management and same-day discharges.

Conclusions

Residents describe learning breast surgery ERAS and postoperative pain management by imitating their seniors, observing patient encounters, completing templated orders, and translating concepts from other ERAS services more so than from formal lectures. When implementing breast ERAS protocols, it is important to consider how informal learning and local culture influence pain management and discharge practices. Ultimately, residents believe in ERAS and often request further educational tools to better connect the daily how-to of breast ERAS pathways with the why behind the enhanced recovery principles.

Patient Factors Associated with High Opioid Consumption after Common Surgical Procedures Following State-Mandated Opioid Prescription Regulations

BACKGROUND

State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score.

STUDY DESIGN

Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis.

RESULTS

A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use.

CONCLUSIONS

Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

Pain management practices for outpatients with breast cancer

Objectives

Methods

Results

Conclusions

•

One in four women office visits for breast cancer received pain medication prescriptions.

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Among the patients receiving pain medications, one in seven women received opioids.

•

Both patient and provider characteristics contribute to variations in pain management in breast cancer patients.

Postoperative Analgesia in Modified Radical Mastectomy Patients After Instillation of Bupivacaine Through Surgical Drains

Background: In contrast to other breast surgeries, modified radical mastectomy (MRM) with axillary lymph node clearance involves intense tissue dissection, with postoperative seroma formation and pain being the major complaints affecting patients. Among these, 40% of females experience acute postoperative pain, and between 25 to 60% develop persistent chronic postsurgical pain. The rationale of this study was that minimally invasive procedures can result in immediate pain relief in patients undergoing mastectomy, which has been proven to satisfy their needs and lead to early discharge in the local population.

Objective: This study determined to find out the efficacy of instilling bupivacaine on wounds by means of surgical drains in controlling pain after MRM.

Methodology: This was a randomized control study trial that was carried out in Surgical Unit 1, Ward 3, Jinnah Postgraduate Medical Centre, Karachi, from November 2020 to April 2021. All patients tested negative for coronavirus disease 2019 (COVID-19) by PCR test before randomly allocating them into two groups. Thirty women in Group B received 40 ml of 0.25% injection bupivacaine, and 30 in Group C received no drug. Duration of analgesia was recorded as time in hours when the patient was received after surgery in the post-anesthesia care unit until the patient felt ache and discomfort of > three scores according to the visual analog pain score chart (VAS).

Results: The average age was 52.48±4.76 years. The mean period of time during which analgesia was observed was significantly higher in Group B as compared to Group C (10.93±1.84 vs 5.03±1.35 hours, p=0.0005).

Conclusion: There is improvement in postoperative analgesia after instilling bupivacaine through surgical drains on wound beds in MRM patients.

Patient-reported opioid analgesic use after discharge from surgical procedures: a systematic review

OBJECTIVE

This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use post-surgery.

METHODS

We searched Pubmed (February 2019), Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized use, and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale.

RESULTS

Ninety-six studies met eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5 mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as < 5 tablets. In studies that examined excess tablets, 25%-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50%-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies due to heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria.

CONCLUSION

Self-reported post-surgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.

Opioid prescribing exceeds consumption following common surgical oncology procedures

BACKGROUND AND OBJECTIVES

Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures.

METHODS

We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices.

RESULTS

Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them.

CONCLUSIONS

This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.

Cancer survivorship and its association with perioperative opioid use for minor non-cancer surgery

PURPOSE

Reducing high-risk prescription opioid use after surgery has become a key strategy in mitigating the opioid crisis. Yet, despite their vulnerabilities, we know little about how cancer survivors use opioids for non-cancer perioperative pain compared to those with no history of cancer. The purpose was to examine the association of cancer survivorship with the likelihood of receiving perioperative opioid therapy for non-cancer minor surgery.

METHODS

Using 2007-2014 SEER-Medicare data for breast, colorectal, prostate, and non-cancer populations, we conducted retrospective cohort study of opioid-naïve Medicare beneficiaries who underwent one of six common minor non-cancer surgeries. Modified Poisson regression estimated the relative risk of receiving a perioperative opioid prescription associated with cancer survivorship compared to no history of cancer. Stabilized inverse probability of treatment weights were used to balance measurable covariates between cohorts.

RESULTS

We included 1486 opioid-naïve older adult cancer survivors and 3682 opioid-naïve non-cancer controls. Cancer survivorship was associated with a 5% lower risk of receiving a perioperative opioid prescription (95% confidence interval: 0.89, 1.00; p = 0.06) compared to no history of cancer. Cancer survivorship was not associated with the extent of perioperative opioid exposure.

CONCLUSION

Cancer survivors were slightly less likely to receive opioid therapy for non-cancer perioperative pain than those without a history of cancer. It is unclear if this reflects a reduced risk of opioid-related harms for cancer survivors or avoidance of appropriate perioperative pain therapy. Further examination of cancer survivors' experiences with and attitudes about opioids may inform improvements to non-cancer pain management for cancer survivors.

Ropivacaine infiltration analgesia of the drainage exit site enhanced analgesic effects after breast Cancer surgery: a randomized controlled trial

BACKGROUND

Postoperative pain after breast cancer surgery remains a major challenge in patient care. Local infiltration analgesia is a standard analgesic technique used for pain relief after surgery. Its application in patients who underwent mastectomy requires more clear elucidation. This study aimed to investigate the effect of ropivacaine infiltration of drainage exit site in ameliorating the postoperative pain after mastectomy.

METHODS

A prospective randomized controlled study was conducted in 74 patients who were scheduled for unilateral mastectomy by standardized general anesthesia. Both intervention group and control group were given infiltration of the two entry points of drainage catheters with 10 ml 0.5% ropivacaine (Group A) (n = 37) or 10 ml normal saline (Group B) (n = 37). Pain scores were recorded in post-anesthesia care unit (PACU), at 6 h, 12 h, 24 h and 36 h after operation by using a visual analogue scale (VAS). Postoperative nausea and vomiting (PONV) incidence, postoperative analgesic and antiemetic requirements, the incidence of chronic pain, as well as the quality of recovery were recorded.

RESULTS

The patients in Group A showed a significant reduction in postoperative pain in PACU (p < 0.0005), at 6 h (p < 0.0005), 12 h (p < 0.0005), and 24 h after surgery (p < 0.05) when compared to those in Group B. There were more postoperative analgesic requirements in Group B (p < 0.05). With regard to the quality of recovery, Group A was shown to be much superior over Group B (p < 0.05).

CONCLUSIONS

Ropivacaine infiltration of the two drainage exit sites decreased the degree of postoperative acute pain after mastectomy, and this approach improved patients' quality of recovery.

TRIAL REGISTRATION

retrospectively registered in Chictr.org.cn registry system on 24 February 2020 ( ChiCTR2000030139 ).

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons

Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

Standardizing Opioid Prescriptions to Patients After Ambulatory Oncologic Surgery Reduces Overprescription

BACKGROUND

Overprescribing of opioids after surgery contributes to long-term abuse. Evaluating opioid prescription patterns and patient-reported opioid use offers an evidence-based method to identify potential overprescription. This quality improvement initiative aimed to reduce and standardize opioid prescriptions upon discharge from an ambulatory oncologic surgery center and evaluate the effect of this change on patients' subsequent opioid use and reported pain.

METHODS

Between March 2018 and January 2019, consecutive opioid-naïve patients aged ≥ 18 years who underwent robotic or laparoscopic hysterectomy, radical prostatectomy, or partial nephrectomy, or total mastectomy with or without immediate reconstruction were surveyed 7-10 days postoperatively. Data collected in the pre- (n = 551) and post-standardization (n = 480) cohorts included perception of pain relief, opioids prescribed (verified by electronic medical record review) and consumed, and refills received.

RESULTS

Pre-standardization, the median opioid prescription at discharge was 20 pills (interquartile range [IQR] 20-28) or 140 oral morphine milligram equivalents (MME) (IQR 100-150). Median opioid consumption was 2 pills (IQR 0-7) or 10 MME (IQR 0-40) among all services. Opioid prescriptions were later standardized to 7, 8, and 10 pills (35, 40, and 75 MME), in the gynecology, urology, and breast services, respectively. The change was not associated with an increase in reported pain. Refill requests increased postintervention across all surgeries from 4.4% to 7.7%, with the largest increase among patients who underwent breast surgery.

CONCLUSION

The number of opioid pills given at discharge to patients undergoing ambulatory or short-stay cancer surgery can safely be reduced.

Reassessing Opioid Use in Breast Surgery

BACKGROUND

This study aims to assess multimodal pain management and opioid prescribing practices in patients undergoing breast surgery.

METHODS

A retrospective review of patients undergoing breast surgery at an academic medical center between April 1, 2018 and September 30, 2019, was performed. Patients with a history of recent opioid use or conditions precluding use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) were excluded. Opioid-sparing pain regimens were assessed. Opioids prescribed on discharge were recorded as oral morphine equivalents (OMEs) and concordance with the Opioid Prescribing Engagement Network (OPEN) determined.

RESULTS

The total study population consisted of 518 patients. 358 patients underwent minor outpatient procedures (sentinel lymph node biopsy, lumpectomy, and excisional biopsy), 10-40% of whom were appropriately prescribed as per the OPEN. Perioperatively, 53.9% of patients received APAP, 24.6% NSAIDs, 20.4% gabapentin, and 0.3% blocks; intraoperatively, 95.8% received local anesthetic and 25.7% ketorolac. For mastectomy without reconstruction, 63-88% of prescriptions were concordant with the OPEN. For mastectomy with reconstruction, discharge opioids ranged from 25 to 400 OMEs with a mean of 134.4 OMEs; 25% of patients received a refill. Of all patients undergoing mastectomy ± reconstruction, 62.5% received APAP, 18.8% NSAIDs, 38.8% pregabalin, and 20.6% locoregional block perioperatively; 37.5% received local anesthetic and 15.6% ketorolac intraoperatively. Of 143 inpatient stays, 89% received APAP, 38% NSAID, and 29% benzodiazepines; 29 patients received no opioids inpatient but were still prescribed 25-200 OMEs on discharge.

CONCLUSIONS

There is need for a multidisciplinary approach to pain management with the use of enhanced recovery after surgery protocols as potential means to standardize perioperative regimens and mitigate opioid overprescription.

Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review

Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America.