A Systematic Review of Perioperative Opioid Management for Minimally Invasive Hysterectomy

Postoperative Opioid Administration and Prescription Practices Following Hysterectomy in Two Tertiary Care Centres: A Comparative Cohort Study between Canada and Austria

Background: In light of the opioid epidemic, opioid-prescribing modalities for postoperative pain management have been discussed controversially and show a wide variation across geographic regions. The aim of this study was to compare postoperative pain treatment regimes. Methods: We performed a matched cohort study of women undergoing hysterectomy in Austria (n = 200) and Canada (n = 200). We aimed to compare perioperative opioid medications, converted to morphine equivalent dose (MED) and doses of non-opioid analgesic (NOA) within the first 24 h after hysterectomy, and opioid prescriptions at discharge between the two cohorts. Results: The total MED received intraoperatively, in the post-anaesthesia care unit (PACU) and during the first 24 h after surgery, was similar in both cohorts (145.59 vs. 137.87; p = 0.17). Women in the Austrian cohort received a higher MED intraoperatively compared to the Canadian cohort (117.24 vs. 79.62; p < 0.001) but a lower MED in the PACU (25.96 vs. 30.42; p = 0.04). The primary outcome, MED within 24 h in the postoperative ward, was markedly lower in the Austrian compared to the Canadian cohort (2.36 vs. 27.98; p < 0.001). In a regression analysis, only the variables "Country" and "mode of hysterectomy" affected this outcome. A total of 98.5% in the Canadian cohort were given an opioid prescription at discharge vs. 0% in the Austrian cohort. Conclusions: Our analysis reveals marked differences between Austria and Canada regarding pain management practices following elective hysterectomy; the significantly higher intraoperative and significantly lower postoperative MED administration in the Austrian cohort compared to the Canadian cohort seems to be significantly affected by each country's cultural attitudes towards pain management; this may have significant public health consequences and warrants further research.

Satisfaction with opioid prescription and use after minor gynaecologic surgery: a pilot prospective study

To describe predictors of patient satisfaction with pain control including opioid prescribing practices, patients undergoing minor gynaecologic and urogynaecologic surgeries were included in a prospective cohort study. Satisfaction with postoperative pain control by opioid prescription status was analysed using bivariate analysis and multivariable logistic regression, controlling for potential confounders. Among participants completing both postoperative surveys, 112/141 (79.4%) reported pain control satisfaction by day 1-2 and 118/137 (86.1%) by day 14. While we were underpowered to detect a true difference in satisfaction by opioid prescription, there were no differences in opioid prescription among patients satisfied with pain control [52% vs. 60% (p = .43) among satisfied patients at day 1-2 and 58.5% vs. 37% (p = .08) at day 14]. Significant predictors of pain control satisfaction were postoperative day (POD) 1-2 average pain at rest [aOR 0.72 (95% CI 0.52-0.99), p = .04], rating of shared decision-making [aOR 1.16 (95% CI 1.004-1.34), p = .04], amount of pain relief [aOR 1.28 (95% CI 1.07-1.54), p = .008) and POD 14 shared decision-making rating [aOR 1.45 (95% CI 1.19-1.77), p = .002].Impact StatementWhat is already known on this subject? There are little data published on opioid prescription rates after minor gynaecologic procedures and no formal evidence-based guidance for gynaecologic providers for opioid prescribing. Few publications describe rates of opioid prescription and use following minor gynaecologic procedures. In the setting of a dramatic escalation of opioid misuse in the United States over the last decade, we sought to describe our practice of opioid prescription following minor gynaecologic procedures and answer the question of whether patient satisfaction is affected by opioid prescription, fill and use.What do the results of this study add? Though underpowered to detect our primary outcome, our results suggest that patient satisfaction with pain control may primarily be significantly affected by the patient's subjective assessment of shared decision-making with the gynaecologist.What are the implications of these findings for clinical practice and/or further research? Ultimately, these preliminary findings suggest a larger cohort is needed to answer the question of whether pain control satisfaction is influenced by receipt/fill/use of opioids after minor gynaecologic surgery.

Perioperative opioid dispensing and persistent use after benign hysterectomy: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis was conducted to (1) assess the quantity and dose of perioperatively dispensed opioids for benign hysterectomy by procedure route and (2) identify the predictors of persistent opioid use after the procedure.

DATA SOURCES

PubMed, Web of Science, and Embase were systematically searched from study inception to 25 March 2022.

STUDY ELIGIBILITY CRITERIA

Studies reporting data on opioid dispensing among patients undergoing benign hysterectomy were considered eligible. The primary outcome was the dosage of opioids dispensed perioperatively (from 30 preoperative days to 21 postoperative days). The secondary outcome was the predictors of persistent opioid use after benign hysterectomy (from 3 months to 3 years postoperatively). Total opioid dispensing was measured in morphine milligram equivalents units.

METHODS

The random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals.

RESULTS

A total of 8 studies presenting data on 377,569 women undergoing benign hysterectomy were included. Of these women, 83% (95% confidence interval, 81-84) were dispensed opioids during the perioperative period. The average amount of perioperatively dispensed opioids was 143.5 morphine milligram equivalents (95% confidence interval, 40-247). Women undergoing vaginal hysterectomy were dispensed a significantly lower amount of opioids than those undergoing laparoscopic or abdominal hysterectomies. The overall rate of persistent opioid use after benign hysterectomy was 5% (95% confidence interval, 2-8). Younger patient age (odds ratio, 1.38; 95% confidence interval, 1.17-1.63), smoking history (odds ratio, 1.87; 95% confidence interval, 1.67-2.10), alcohol use (odds ratio, 3.16; 95% confidence interval, 2.34-4.27), back pain (odds ratio, 1.50; 95% confidence interval, 1.10-2.05), and fibromyalgia (odds ratio, 1.60; 95% confidence interval, 1.39-1.83) were significantly associated with a higher risk of persistent opioid use after benign hysterectomy. However, there was no significant effect of hysterectomy route and operative complexity on persistent opioid use postoperatively.

CONCLUSION

Perioperative opioid dispensing was significantly dependent on the route of hysterectomy, with the lowest dispensed morphine milligram equivalents of opioids for vaginal hysterectomy and the highest for abdominal hysterectomy. Nevertheless, hysterectomy route did not significantly predict persistent opioid use postoperatively, whereas younger age, smoking, alcohol use, back pain, and fibromyalgia were significantly associated with persistent opioid use.

Ice-POP: Ice Packs for Postoperative Pain: A Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the benefit of ice packs as a supplement to standard pain management following laparoscopic hysterectomy (LH).

DESIGN

This Institutional Review Board-approved randomized controlled trial involved patients undergoing LH for benign conditions. Subjects were randomized to receive standard enhanced recovery after surgery pain management or standard enhanced recovery after surgery plus ice packs.

SETTING

Two academic tertiary care centers PATIENTS: Patients undergoing planned outpatient LH with the minimally invasive gynecologic surgery team between February 2019 and November 2020 were considered. Patients with chronic pain, current opioid use ≥1 week, or planned overnight hospitalizations were excluded. Primary outcome data were available for 51 subjects (24 control, 27 intervention).

INTERVENTIONS

Ice packs were placed on the abdomen in the operating room.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed at multiple time points throughout the study using a visual analogue scale (VAS). Opioid requirement was assessed using morphine milligram equivalent. There was no difference between the groups on any demographic variables. Morphine milligram equivalent requirements were also not different between the groups (p = .63). Postoperative day 1 (POD#1) VAS scores were not different (p = .89). Eighty-five percent of subjects reported feeling that their pain was controlled. Subjects who reported that they did not feel their pain was controlled did not use more opioids on POD#1 (p = .37), nor did they have higher POD#1 VAS scores (p = .55). Eighty-seven percent of the intervention subjects said they would use ice again, and 82.6% of them said they would recommend ice to others. There were no adverse events related to ice. All subjects were prescribed 20 tablets oxycodone and averaged 2.9 (SD 3.4) tablets used after discharge.

CONCLUSION

Ice packs are an acceptable supplement for postoperative pain control, but they do not reduce postoperative pain or opioid usage compared to standard pain management without ice packs.

Perioperative opioid management for minimally invasive hysterectomy

Given the high volume of hysterectomies performed, the contribution of gynecologists to the opioid crisis is potentially significant. Following a hysterectomy, most patients are over-prescribed opioids, are vulnerable to developing new persistent opioid use, and can be the source of misuse, diversion, or accidental exposure. People who misuse opioids are at risk of an overdose related death, which is now one of the leading causes of death in the United States and is rising in other countries. It is the physician's responsibility to reduce opioid use by making impactful practice changes, such as 1) using pre-emptive opioid sparing strategies, 2) optimizing multimodal nonopioid pain management, 3) restricting postoperative opioid prescribing, and 4) educating patients on proper disposal of unused opioids. These changes can be implemented with an enhanced recovery after surgery protocol, shared decision-making, and patient education strategies related to opioids.

Intraoperative Factors Associated with More Postoperative Opioid Use after Laparoscopic Hysterectomy

BACKGROUND AND OBJECTIVES:

To identify intraoperative factors during laparoscopic hysterectomy associated with postoperative opioid use and increased pain scores during the acute postoperative period.

METHODS:

This is a prospective survey-based cohort study at two teaching hospitals in the Boston metropolitan area. A total of 125 patients undergoing laparoscopic hysterectomy were enrolled. Surveys were administered by telephone at one-week postoperatively and in-person at their two-week postoperative visit to elicit opioid consumption converted to morphine milligram equivalents (MMEs) and pain scores.

RESULTS:

The median total opioid consumption was 37.5 MME (range 0–960 MMEs). Intraoperative factors associated with increased total MME consumption were lower uterine weight and resection of endometriosis at the time of surgery. Patients with uteri less than 250 grams used twice as much opioid compared to participants with uteri greater than 250 grams (median of 49.8 MME (interquartile range [IQR] 7.5–120.5) vs. 22.5 MME (IQR 7.5–61.0). The median opioid consumption by patients with resection or ablation of endometriosis was three times that of those who did not undergo surgical treatment of endometriosis (97.0 MME (IQR 53.1–281.3) vs. 30.0 MMEs (IQR 7.5–81.3 MME)). Maximum pain scores and reported pain score at one and two-week interviews were also significantly higher in patients with these characteristics.

CONCLUSION:

Several easily identified intraoperative factors may be correlated with opioid requirements during the acute postoperative period. This can allow surgeons to set expectations and dispense patient-specific opioid prescriptions. Individualizing prescriptions may lower the amount of excess circulating opioids and help combat the opioid epidemic.

Risk Factors for Postoperative Narcotic Use in Benign, Minimally-Invasive Gynecologic Surgery

Background and Objectives:

To evaluate postoperative opioid use after benign minimally-invasive gynecologic surgery and assess the impact of a patient educational intervention regarding proper opioid use/disposal.

Methods:

Educational pamphlets were provided preoperatively. Patients underwent hysterectomy, myomectomy, or other laparoscopic procedures. Opioid prescriptions were standardized with 25 tablets oxycodone 5mg for hysterectomy/myomectomy, 10 tablets oxycodone 5mg for LSC (oral morphine equivalents were maintained for alternatives). Pill diaries were reviewed and patient surveys completed during postoperative visits.

Results:

Of 106 consented patients, 65 (61%) completed their pill diaries. Median opioid use was 35 OME for hysterectomy (∼5 oxycodone tablets; IQR 11.25-102.5), 30 OME for myomectomy (∼4 tablets; IQR 15-75), and 18.75 OME for laparoscopy (∼3 tablets; IQR 7.5-48.75). Median last post-operative day (d) of use was 3d for hysterectomy (IQR 2, 8), 4d for myomectomy (IQR 1, 7), and 2d for laparoscopy (IQR 0.5-3.5). One patient (myomectomy) required a refill of 5mg oxycodone. No difference was found between total opioid use and presence of pelvic pain, chronic pain disorders, or psychiatric co-morbidities. Overall satisfaction with pain control (>4 on a 5-point Likert scale) was 91% for hysterectomy, 100% for myomectomy, 83% for laparoscopy. Of the 33 patients who read the pamphlet, 32(97%) felt it increased their awareness.

Conclusion:

Most patients required <10 oxycodone 5mg tablets, regardless of procedure with excellent patient satisfaction. A patient education pamphlet is a simple method to increase knowledge regarding the opioid epidemic and facilitate proper medication disposal.

Updates in Enhanced Recovery Pathways for Gynecologic Surgery

Gynecologic surgery encompasses over a quarter of inpatient surgical procedures for US women, and current projections estimate an increase of the US female population by nearly 50% in 2050. Over the last decade, US hospitals have embraced enhanced recovery pathways in many specialties. They have increasingly been used in multiple institutions worldwide, becoming the standard of care for patient optimization. According to the last updated enhanced recovery after surgery (ERAS) guideline published in 2019, there are several new considerations behind each practice in ERAS protocols. This article discusses the most updated evidence regarding ERAS programs for gynecologic surgery.

Patterns of narcotic utilization in women undergoing hysterectomy for benign indications

OBJECTIVE

To determine whether perioperative narcotic utilization at the time of hysterectomy has decreased since 2012.

STUDY DESIGN

Retrospective cohort study.

SETTING

Academic university hospital.

PATIENTS

Patients who underwent a laparoscopic hysterectomy for benign indications between January 2012 and December 2018.

INTERVENTIONS

Perioperative narcotics administration.

MEASUREMENTS AND MAIN RESULTS

We identified 651 patients who underwent a hysterectomy for benign indications from 2012 to 2018. Of these, 377 surgeries were performed using robotic-assistance (58%) and the remainder (42%) were performed by conventional laparoscopy. Narcotic utilization declined significantly by year for both intra-operative and post-operative periods (both p<.001). The largest decline for intraoperative morphine milligram equivalents (MME) was between 2016 and 2017, while for post-operative MME, it was between 2012 and 2013. The pattern remained significant after adjusting for covariates. Intraoperative MME administration was correlated with postoperative MME use (Spearman r = 0.23, p<.001). Of the demographic variables only Body Mass Index was significantly associated with perioperative narcotic administration.

CONCLUSION

Administration of opioids for intraoperative and postoperative pain after minimally invasive hysterectomy substantially decreased from 2012 to 2018. Intraoperative narcotic utilization was correlated with immediate postoperative narcotic consumption. Heightened awareness of opioid administration practices during and immediately following surgery is critically important to decreasing risk of chronic opioid dependence and providing the best possible care for the patients we serve.

Postoperative Opioid Utilization in Older Women Undergoing Pelvic Organ Prolapse Surgery

OBJECTIVES

The objective of this study was to determine total postoperative opioid consumption by women 60 years and older during the first week after pelvic organ prolapse surgery. We secondarily aimed to describe opioid prescribing patterns in this cohort.

METHODS

This is a secondary analysis of a prospective cohort study assessing changes in cognition in women 60 years and older undergoing prolapse surgery. Postoperative opioid use at home during the first week was collected through daily self-reported diary entries. Total postoperative opioid consumption was calculated by adding opioid administration in the postoperative anesthesia recovery unit, inpatient setting, and home opioid use (as documented in diary). Regression models were used to identify demographic and clinical factors associated with total postoperative opioid consumption in the top quartile of this cohort and home opioid use.

RESULTS

Data from 80 women were analyzed. Mean ± SD age was 71.78 ± 6.14 years (range, 60-88 years). Fifty women (62.5%) underwent vaginal surgery, and 30 (7.5%) underwent laparoscopic/robotic surgery, with concomitant hysterectomy in 47 (58.8%). The median (interquartile range) total morphine milligram equivalents used during the first week after surgery was 30 (7.5-65.75). The median (interquartile range) total morphine milligram equivalents prescribed was 225 (150-225).

CONCLUSIONS

Opioid consumption after prolapse surgery in older women is very modest and equates to a median (interquartile range) of 4 (1-9) oxycodone (5 mg) tablets. Opioid prescribing patterns should be adjusted accordingly.

Opioid Education in Obstetrics and Gynecology Training Programs

OBJECTIVE

Our primary objective was to assess the current state of pain and opioid education in obstetrics and gynecology (OBGYN) by performing a detailed review of the national educational curricula guiding OBGYN residency and fellowship training programs in the United States.

METHODS

From 2019 to 2020 we reviewed seven documents created to guide learning and structure educational training for OBGYN residency and fellowship programs in the United States: the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives Core Curriculum in Obstetrics and Gynecology, the 2016 Educational Objectives-Fellowship in Minimally Invasive Gynecologic Surgery, and the 2018 Guides to Learning in Complex Family Planning, Female Pelvic Medicine & Reconstructive Surgery, Gynecologic Oncology, Maternal Fetal Medicine, and Reproductive Endocrinology and Infertility. Each document was reviewed by two authors to assess for items referring to pain or opioids.

RESULTS

The CREOG educational objectives, used to inform educational curricula for residency programs, were the most comprehensive, mentioning pain and/or opioid educational objectives the highest number of times and including the most categories. The CREOG document was followed by the Guides to Learning for Gynecologic Oncology and for Minimally Invasive Gynecologic Surgery. The Reproductive Endocrinology and Infertility Guide to Learning did not mention pain and/or opioids in the educational objectives.

CONCLUSIONS

Our study identifies an opportunity for consistent and appropriate opioid and pain management education in OBGYN training.

Opioid Prescribing Practices for Women Undergoing Elective Gynecologic Surgery

STUDY OBJECTIVE

To describe the opioid prescribing practices in opioid-naive women undergoing elective gynecologic surgery for benign indications and identify risk factors associated with increased perioperative opioid use. We also explored factors associated with new persistent opioid use in women with perioperative opioid use.

DESIGN

Retrospective, population-based cohort study.

SETTING

We used linked administrative data from a government-administered single-payer provincial healthcare system in Canada. This study was undertaken at ICES, a not-for-profit research institute in Ontario, Canada.

PATIENTS

We followed opioid-naive adult women who underwent benign elective gynecologic surgery between 2013 and 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was perioperative opioid use defined as ≥1 opioid prescription from 30 days before to 14 days after surgery. New persistent opioid use after gynecologic surgery was defined as having filled 1 or more opioid prescriptions between 91 days and 180 days postoperatively. Multivariable log-linear regression analyses were employed to adjust for clinical and demographic data. Of the 132 506 patients included in our cohort, most (74.3%) underwent minor gynecologic procedures. Perioperative opioid use was documented in 27 763 (21.0%) patients, and there was a significant decreasing trend (p <.001) in the proportion of patients with perioperative opioid use from 21.8% in 2013 to 18.5% in 2018. Factors associated with increased perioperative opioid use included younger age; higher income quintile; urban dwellers; and diagnosis of infertility, endometriosis, or adnexal mass. Perioperative opioid use was an independent risk factor for persistent use (adjusted relative risk 1.40; 95% confidence interval, 1.13-1.72) and for every 65 patients prescribed opioids associated with gynecologic surgery, one developed new persistent opioid use. The highest risk factor for developing persistent use was filling a high-dose opioid prescription (adjusted relative risk_{5th quintileOME} 2.33; 95% confidence interval, 1.83-2.96).

CONCLUSION

One in 5 women who undergo a gynecologic procedure has a new exposure to opioids. For every 65 patients who fill an opioid prescription after their gynecologic surgery, one will experience prolonged opioid use.

Opioid Prescriptions for Female Pelvic Reconstructive Surgery Patients Before and After Implementation of Tennessee State Legislation

OBJECTIVES

Limited data exist regarding the impact of state legislation on opioid-prescribing patterns, particularly in states with the highest opioid-prescribing rates in the nation. Our primary objective was to examine the change in the amount of opioid morphine equivalents (OMEs) prescribed at discharge to patients undergoing female pelvic reconstructive surgery after the implementation of state legislation created in response to the opioid crisis.

METHODS

At our institution, state legislation went into effect on July 1, 2018, implementing limitations on OMEs prescribed to patients. This retrospective cohort study examines all adult women undergoing female pelvic reconstructive surgery from January 1, 2018, to December 31, 2018. The study compares prescribing practices 6 months before and 6 months after the state law was enacted.

RESULTS

In total, 346 patients met inclusion criteria. The 2 groups had similar demographics. Surgical procedures were well distributed, with 52% of cases occurring in the first 6 months of the calendar year. At the time of discharge, 324 (96.7%) patients received an opioid prescription, with an overall average of 197 OMEs. After the implementation of state legislation on July 1, 2018, the amount of OMEs prescribed at discharge significantly decreased, from a median of 210 mg (interquartile range, 150-225) to 150 mg (interquartile range 135-225; P = 0.02).

CONCLUSIONS

State legislation was associated with a significant decrease in prescribed OMEs at the time of discharge in patients undergoing female pelvic reconstructive surgery. These results support ongoing legislative efforts to address the current opioid crisis.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Abdominal Ice after Laparoscopic Hysterectomy: A Randomized Controlled Trial

STUDY OBJECTIVE

To assess the impact of abdominal ice packs on opioid use and pain control after laparoscopic hysterectomy DESIGN: Randomized controlled trial.

SETTING

Academic tertiary care medical center.

PATIENTS

Total of 142 adult women undergoing laparoscopic (either conventional or robotic) hysterectomy were randomized to control (n = 69) or intervention (n = 73). Exclusion criteria included preoperative opioid use, planned intensive care unit admission or same-day discharge, an incision ≥4 cm, and regional anesthesia use.

INTERVENTIONS

Subjects in the intervention group had a large ice pack placed directly on the lower abdomen before leaving the operating room. The ice pack was maintained continuously for 12 hours postoperation, as desired thereafter until discharge, and continued use encouraged after discharge for up to 48 hours.

MEASUREMENTS AND MAIN RESULTS

Total opioids administered postoperatively, while inpatient and after dismissal, were assessed in morphine milligram equivalents. Postoperative pain, as well as analgesia acceptability and side effects, were assessed using validated measures: Brief Pain Inventory and Overall Benefit of Analgesia Score. Median morphine milligram equivalent was lower in the intervention group than the controls from inpatient stay on the floor to completion of opioid use as an outpatient (22.5 vs 26.2) but was not statistically significant (p = .79). There was no significant difference between the groups in Brief Pain Inventory assessment of postoperative pain severity (p = .80) or pain interference (p = .36) or Overall Benefit of Analgesia Score total score (p = .88). Most patients in the intervention group were very satisfied with ice pack use (n = 51, 79.7%) and very likely to recommend it to friends or family (n = 54, 83.1%). There were no adverse events related to ice pack use.

CONCLUSION

There was no significant difference in postoperative opioid use or pain assessment with ice pack use after laparoscopic hysterectomy. However, most of the subjects expressed high satisfaction specific to ice pack use and would recommend its use to others, suggesting potential desirability as adjunct therapy in postoperative pain control.

Perioperative pain management in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery.

RECENT FINDINGS

With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing.

SUMMARY

Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.

Persistent Opioid Use After Hysterectomy in the United States, 2005-2015

OBJECTIVE

To assess variables associated with opioid prescriptions filled perioperatively after hysterectomy and the risk of prolonged opioid use through 1 year after hysterectomy.

METHODS

In this retrospective cohort study, we used the 2005-2015 IBM MarketScan databases to identify women aged at least 18 years who underwent hysterectomy. For opioid use, we identified filled prescriptions for opioid medications. We excluded women with prevalent opioid use, defined as an opioid prescription filled 180 to 30 days preoperatively or at least two prescriptions filled in the 30 days before surgery. We defined perioperative opioid use as any opioid prescription filled within 30 days before or 7 days after surgery. We used log-binomial regression to identify independent predictors of perioperative opioid prescription fill. To assess the risk of long-term opioid use, we estimated the proportion of women with ongoing monthly opioid prescriptions through 12 months after surgery and the proportion of women with any opioid prescription 3-6 months after surgery, mimicking published estimates.

RESULTS

Among 569,634 women who underwent hysterectomy during the study period, 176,537 (30.9%) were excluded owing to prevalent opioid use. We found that 331,322 (84.3%) women filled a perioperative opioid prescription, with median quantity of 30 pills (interquartile range 25-40), and that younger (adjusted risk ratio [adjRR]18-24 0.91) and older (adjRR65-74 0.84; adjRR75+ 0.70) patients were less likely to receive a perioperative prescription compared with women aged 45-54. The proportion of women with continuous monthly fills of opioids through 2, 3, 6, and 12 months after surgery was 1.40%, 0.34%, 0.06%, and 0.02%, respectively.

CONCLUSION

Most women who underwent hysterectomy in the United States from 2005 to 2015 filled a perioperative opioid prescription with a median quantity of 30 pills. The risk of prolonged opioid use through 6 months is quite low, at 0.06% or 1 in 1,547.