Pain and opioid prescriptions vary by procedure after breast surgery

Association between trajectories of prescription opioid use and risk of opioid use disorder and overdose among US nonmetastatic breast cancer survivors

PURPOSE

To examine the association between prescription opioid use trajectories and risk of opioid use disorder (OUD) or overdose among nonmetastatic breast cancer survivors by treatment type.

METHODS

This retrospective cohort study included female nonmetastatic breast cancer survivors with at least 1 opioid prescription fill in 2010-2019 Surveillance, Epidemiology and End Results linked Medicare data. Opioid mean daily morphine milligram equivalents (MME) calculated within 1.5 years after initiating active breast cancer therapy. Group-based trajectory models identified distinct opioid use trajectory patterns. Risk of time to first OUD/overdose event within 1 year after the trajectory period was calculated for distinct trajectory groups using Cox proportional hazards models. Analyses were stratified by treatment type.

RESULTS

Four opioid use trajectories were identified for each treatment group. For 38,030 survivors with systemic endocrine therapy, 3 trajectories were associated with increased OUD/overdose risk compared with early discontinuation: minimal dose (< 5 MME; adjusted hazard ratio [aHR] = 1.73 [95% CI  1.43-2.09]), very low dose (5-25 MME; 2.67 [2.05-3.48]), and moderate dose (51-90 MME; 6.20 [4.69-8.19]). For 9477 survivors with adjuvant chemotherapy, low-dose opioid use was associated with higher OUD/overdose risk (aHR = 7.33 [95% CI 2.52-21.31]) compared with early discontinuation. For 3513 survivors with neoadjuvant chemotherapy, the differences in OUD/OD risks across the 4 trajectories were not significant.

CONCLUSIONS

Among Medicare nonmetastatic breast cancer survivors receiving systemic endocrine therapy or adjuvant chemotherapy, compared with early discontinuation, low-dose or moderate-dose opioid use were associated with six- to sevenfold higher OUD/overdose risk. Breast cancer survivors at high-risk of OUD/overdose may benefit from targeted interventions (e.g., pain clinic referral).

The Benefits of Local Anesthesia Used in Mastectomy Without Reconstruction

BACKGROUND

The opioid epidemic has driven renewed interest in local anesthesia to reduce postoperative opioid use. Our objective was to determine if local anesthesia decreased hospital pain scores, oral morphine equivalents (OME), length of stay (LOS), and nausea/vomiting.

METHODS

Single institution retrospective study of females who underwent mastectomy without reconstruction.

RESULTS

Overall, 712 patients were included; 63 (8.8%) received bupivacaine (B), 512 (72%) liposomal bupivacaine (LB), and 137 (19%) no local. 95% were discharged on POD1. Liposomal bupivacaine use increased from 2014 to 2019. Additional factors associated with use of local regimen were surgeon and extent of axillary surgery. Fewer patients used postop opioids during their hospital stay if any local was used compared to none (76 vs 88%; 0.003). Compared to none, local had shorter mean PACU LOS (95 vs 87 min; P = .02), lower mean intraoperative-OME (96 vs 106; P < .001), and lower mean postoperative OME/hr (1.4 vs 1.8 P = .001). Multivariable analysis (MVA) showed lower OME/hr with LB compared to B and none (P = .002); this translates to 22 mg and 30 mg of oxycodone in a 24-hr period, respectively. MVA showed lower POD1 pain scores with LB relative to none (P = .049). Local did not impact nausea/emesis.

CONCLUSION

Local anesthesia was superior to no local in several measures. However, a consistent benefit of a specific local anesthetic agent was not demonstrated (LB vs B). A prospective study is warranted to determine the optimal local regimen for this cohort and further inform clinical relevance.

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.

Minimizing opioid consumption by eliminating patient-controlled analgesia after penile inversion vaginoplasty with enhanced recovery after surgery (ERAS) protocol

BACKGROUND

Genital-based gender affirmation surgery is a physically demanding procedure requiring extensive postoperative pain management. However, perioperative opioid use for these procedures is relatively understudied.

OBJECTIVES

This study analyzes whether intravenous patient-controlled analgesia (PCA) enhances pain control after penile inversion vaginoplasty (PIV) in the setting of enhanced recovery after surgery (ERAS) protocols, and whether non-PCA (NCA)-based regimens could reduce postoperative opioid use.

METHODS

All patients undergoing PIV with ERAS protocols by a single provider from December 2018 to November 2020 were retrospectively reviewed. Patient demographics, comorbid conditions, pain scores, length of stay (LOS), and opioid usage during their hospitalization were collected. Postoperative opioid use and pain scores were compared between PCA and NCA patient cohorts.

RESULTS

A total of 61 patients were included. 30 patients received intravenous PCA postoperatively, and 31 patients used NCA-based narcotic pain control. All patients underwent ERAS protocol perioperatively. Average patient age was 34.5 years (SD 11.9) in the PCA cohort and 37.6 years (SD 11.9) in the NCA cohort (p = 0.242). Average total postoperative opioid use during hospital stay was reduced by 53.7% in the NCA cohort, with an average use of 501.6 morphine milligram equivalents (MME) (SD 410.3) among PCA patients and an average use of 232.0 MME (SD 216.5) among NCA patients (p = 0.003). Daily average pain scores for postoperative days 1 to 6 did not differ between the PCA and NCA patient groups (p > 0.05). Average hospital LOS was shorter among NCA patients, 6.2 days (SD 1.0) versus 7.3 days (SD 1.4), respectively, (p < 0.001).

DISCUSSION

In combination with an ERAS non-narcotic pain control protocol, it may be possible to reduce opioid use by more than 50% and shorten length of postoperative hospital stay among patients by implementing NCA pain management protocols.

CONCLUSION

Minimizing postoperative opioid consumption after PIV will benefit patients and their sustained well-being.

Opioid use and misuse in children, adolescents, and young adults with cancer: a systematic review of the literature

Adolescents and young adults (AYAs) are at increased risk for negative opioid-related outcomes, including misuse and overdose. High-quality cancer care requires adequate pain management and often includes opioids for tumor- and/or treatment-related pain. Little is known about opioid use and misuse in children and AYAs with cancer, and we therefore conducted a systematic review of the literature using PRISMA guidelines to identify all relevant studies that evaluated opioid use and/or misuse among this population. Eleven studies were identified that met our inclusion criteria. The range of opioid use among the studies was 12-97%, and among the five studies that reported opioid misuse or aberrant behaviors, 7-90% of patients met criteria. Few studies reported factors associated with opioid misuse but included prior mental health and/or substance use disorders, and prior opioid use. In summary, opioid use is highly variable among children and AYAs with cancer; however, the range of use varies widely depending on the study population, such as survivors or end-of-life cancer patients. Few studies have examined opioid misuse and/or aberrant behaviors, and future research is needed to better understand opioid use and misuse among children and AYAs with cancer, specifically those who will be cured of their cancer and may subsequently experience adverse opioid-related outcomes.

Chronic Breast Pain Prior to Breast Cancer Surgery Is Associated with Worse Acute Postoperative Pain Outcomes

Acute postoperative pain is associated with adverse short and long-term outcomes among women undergoing surgery for breast cancer. Previous studies identified preexisting pain as a predictor of postoperative pain, but rarely accounted for pain location or chronicity. This study leveraged a multinational pain registry, PAIN OUT, to: (1) characterize patient subgroups based on preexisting chronic breast pain status and (2) determine the association of preexisting chronic pain with acute postoperative pain-related patient-reported outcomes and opioid consumption following breast cancer surgery. The primary outcome was a composite score comprising the mean of pain intensity and pain interference items from the International Pain Outcomes Questionnaire. The secondary outcome was opioid consumption in the recovery room and ward. Among 1889 patients, we characterized three subgroups: no preexisting chronic pain (n = 1600); chronic preexisting pain elsewhere (n = 128) and; chronic preexisting pain in the breast with/without pain elsewhere (n = 161). Controlling for covariates, women with preexisting chronic breast pain experienced more severe acute postoperative pain and pain interference (β = 1.0, 95% CI = 0.7-1.3, p < 0.001), and required higher doses of opioids postoperatively (β = 2.7, 95% CI = 0.6–4.8, p = 0.013). Preexisting chronic breast pain may be an important risk factor for poor pain-related postoperative outcomes. Targeted intervention of this subgroup may improve recovery.

Older Women and Opioid Analgesia after Breast Cancer Surgery

PURPOSE

To explore which factors influence opioid analgesia use in older women during the 48-hour period after hospital discharge following initial breast cancer surgery.

DESIGN

This cross-sectional, descriptive study involved a cohort (n = 57) of older women recruited for a larger study of breast cancer patients.

METHODS

We gathered patient-reported data pertinent to perioperative and post-discharge pain control. Data were analyzed using linear regression to explore those characteristics that had the greatest influence on the amount of post-discharge opioid analgesia required.

RESULTS

After hospital discharge, 29 older women (51%) with breast cancer avoided opioid analgesia for various reasons. The number of prescribed opioid tablets each woman self-administered determined the total dosage of analgesia required 48 hours post-discharge.

CONCLUSIONS

The majority of this sample of older women with early-stage breast cancer experienced adequate pain relief after surgery and required little or no postoperative or postdischarge opioid analgesia. Optimization of the pain control experience for older women with breast cancer requires thorough pain assessment from diagnosis through survivorship through the end of life. This can be achieved by equipping women in this population to advocate for their pain control needs in real time. Future studies that elucidate preferences, beliefs, and current pain control practices before, during, and after breast cancer surgery will improve safety and efficacy of pain control for this fast-growing population.

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.