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Kurteva S, Pook M, Fiore JF, Tamblyn R. Rates and risk factors for persistent opioid use after cardiothoracic surgery: A cohort study. Surgery 2024; 175:271-279. [PMID: 38008605 DOI: 10.1016/j.surg.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/25/2023] [Accepted: 10/25/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND This study's aim was to estimate potential risk factors for persistent opioid use after cardiothoracic surgery. METHODS This study included participants in the McGill University Health Centre clinical trial (2014 to 2016). Provincial medical services, prescription claims, and medical charts data were linked. Persistent opioid use was defined as an initial peri-operative opioid dispensation followed by an opioid dispensation between 91 and 180 days postdischarge. Multivariable Cox Proportional Hazards models were used to assess factors associated with persistent opioid use. RESULTS A cohort of 815 patients (mean age: 68.9 [standard deviation = 8.9]) was assembled, of which 8.2% became persistent opioid users. Factors such as higher Charlson Comorbidity Index (adjusted hazard ratio: 3.4, 95% confidence interval: 1.1-10.6), history of diabetes (adjusted hazard ratio: 2.1, 95% confidence interval: 1.3-3.4), substance and alcohol abuse (adjusted hazard ratio: 16.3, 95% confidence interval: 5.3-49.5), and radiotherapy (adjusted hazard ratio: 2.4, 95% confidence interval: 1.5-4.1) were associated with a higher hazard of persistent opioid use. Previous opioid use (adjusted hazard ratio: 1.7, 95% CI: 1.0-2.8), daily peri-operative opioid dose (adjusted hazard ratio: 2.3, 95% confidence interval: 1.5-3.7), having an opioid dispensation 30 days pre-admission (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), and pre-admission analgesic use (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), were also associated with an increased hazard of persistent use. Being prescribed multimodal analgesia at discharge (adjusted hazard ratio: 0.54, 95% confidence interval: 0.32-0.92) was associated with a 46% decreased hazard of developing persistent opioid use. CONCLUSION Multiple patient- and medication-related characteristics were associated with an increased hazard of persistent opioid use.
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Affiliation(s)
- Siyana Kurteva
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, McGill University, Montreal, Canada.
| | - Makena Pook
- Division of Experimental Surgery, McGill University, Montreal, Canada
| | - Julio Flavio Fiore
- Division of Experimental Surgery, McGill University, Montreal, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada; Department of Medicine, McGill University Health Center, Montreal, Canada
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Merchant SJ, Shellenberger JP, Sawhney M, La J, Brogly SB. Physician Characteristics Associated With Opioid Prescribing After Same-Day Breast Surgery in Ontario, Canada: A Population-Based Cohort Study. ANNALS OF SURGERY OPEN 2023; 4:e365. [PMID: 38144500 PMCID: PMC10735111 DOI: 10.1097/as9.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/28/2023] [Indexed: 12/26/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Monakshi Sawhney
- Department of Anesthesiology and Perioperative Medicine, School of Nursing, Queen’s University, Kingston, Ontario, Canada
| | - Julie La
- From the Department of Surgery, Queen’s University
| | - Susan B. Brogly
- From the Department of Surgery, Queen’s University
- ICES Queen’s
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La J, Alqaydi A, Wei X, Shellenberger J, Digby GC, Brogly SB, Merchant SJ. Variation in opioid filling after same-day breast surgery in Ontario, Canada: a population-based cohort study. CMAJ Open 2023; 11:E208-E218. [PMID: 36882209 PMCID: PMC10000904 DOI: 10.9778/cmajo.20220055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
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.
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Affiliation(s)
- Julie La
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Anood Alqaydi
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Xuejiao Wei
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Jonas Shellenberger
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Geneviève C Digby
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Susan B Brogly
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Shaila J Merchant
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont.
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Jogerst K, Coe TM, Gupta N, Pockaj B, Fingeret A. How to teach ERAS protocols: surgical residents' perspectives and perioperative practices for breast surgery patients. GLOBAL SURGICAL EDUCATION : JOURNAL OF THE ASSOCIATION FOR SURGICAL EDUCATION 2023; 2:33. [PMID: 38013861 PMCID: PMC9904524 DOI: 10.1007/s44186-022-00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/16/2022] [Accepted: 09/15/2022] [Indexed: 11/29/2023]
Abstract
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.
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Affiliation(s)
- Kristen Jogerst
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Taylor M. Coe
- Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Nikita Gupta
- Alix School of Medicine, Mayo Clinic Arizona, Phoenix, AZ USA
| | - Barbara Pockaj
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 USA
| | - Abbey Fingeret
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE USA
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Pawloski KR, Sevilimedu V, Twersky R, Tadros AB, Kirstein LJ, Cody HS, Morrow M, Moo TA. Association Between Local Anesthetic Dosing, Postoperative Opioid Requirement, and Pain Scores After Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2022; 29:1737-1745. [PMID: 34694521 PMCID: PMC11110646 DOI: 10.1245/s10434-021-10981-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/05/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Multimodal analgesia (MMA) during breast surgery reduces postoperative pain and opioid requirements, but the relative contribution of local anesthetic dosing as a component of MMA is not well defined among patients undergoing lumpectomy and sentinel lymph node biopsy (SLNB). PATIENTS AND METHODS We identified consecutive patients who underwent lumpectomy and SLNB with MMA from 1/2019 to 4/2020. Univariable and multivariable linear and logistic regression were used to examine associations between local anesthetics, opioid requirements in the post-anesthesia care unit (PACU), and pain scores in the PACU and on postoperative day (POD) 1. RESULTS In total, 1603 patients [median tumor size, 14 mm (interquartile range 8-20 mm)] were included. The median PACU opioid requirement was 0 morphine milligram equivalents (interquartile range 0-5). PACU maximum pain was none or mild in 58% of patients and moderate to severe in 42%; among 420 survey respondents, 56% reported no or mild pain and 44% reported moderate to severe pain on POD 1. On multivariable analysis that adjusted for routine components of MMA, increasing doses of 0.5% bupivacaine were associated with reduced PACU opioid requirements (β -0.04, 95% confidence interval -0.07 to -0.01, p = 0.011) and lower odds of moderate to severe pain (odds ratio 0.98, 95% confidence interval 0.97-0.99, p < 0.001). Local anesthetics were not associated with pain scores on POD 1. CONCLUSIONS Higher amounts of local anesthetics reduce acute postoperative pain and opioid requirement after lumpectomy and SLNB. Maximizing dosing within weight-based limits is a low-risk, cost-effective pain control strategy that can be used in diverse practice settings.
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Affiliation(s)
- Kate R Pawloski
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Biostatistics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rebecca Twersky
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree B Tadros
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie J Kirstein
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hiram S Cody
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Beauchemin M, Dorritie R, Hershman DL. Opioid use and misuse in children, adolescents, and young adults with cancer: a systematic review of the literature. Support Care Cancer 2021; 29:4521-4527. [PMID: 33462726 PMCID: PMC8238862 DOI: 10.1007/s00520-020-05980-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/29/2020] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Melissa Beauchemin
- Mailman School of Public Health, Department of Epidemiology, Columbia University, 722 W. 168th Street Room 719, NY, 10032, New York, USA.
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, 10032, USA.
| | | | - Dawn L Hershman
- Mailman School of Public Health, Department of Epidemiology, Columbia University, 722 W. 168th Street Room 719, NY, 10032, New York, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, 10032, USA
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7
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Pawloski KR, Matar R, Sevilimedu V, Tadros AB, Kirstein LJ, Cody HS, Van Zee KJ, Morrow M, Moo TA. Postdischarge Nonsteroidal Anti-Inflammatory Drugs Are not Associated with Risk of Hematoma after Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2021; 28:5507-5512. [PMID: 34247337 PMCID: PMC8272604 DOI: 10.1245/s10434-021-10446-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly used in ambulatory breast surgery. The risk of hematoma associated with intraoperative ketorolac is low, but whether concomitant routine discharge with NSAIDs increases the risk of hematoma is unclear. Methods We retrospectively identified patients who underwent lumpectomy and sentinel lymph node biopsy (SLNB), and compared the 30-day risk of hematoma between patients discharged with opioids (opioid period: January 2018–August 2018) and patients discharged with NSAIDs with or without opioids (NSAID period: January 2019–April 2020). The association between study period and hematoma risk was assessed using multivariable models. Covariates included intraoperative ketorolac, home aspirin, and race/ethnicity. During the NSAID period, a survey was used to assess analgesic consumption on postoperative days 1–5. Results In total, 2724 patients were identified: 858 (31%) in the opioid period and 1866 (69%) in the NSAID period. In the NSAID period, 867 (46%) received NSAIDs and opioids, and 999 (54%) received NSAIDs only. Receipt of intraoperative ketorolac was higher in the NSAID period (78 vs. 64%, P < 0.001). The risks of any hematoma (4.1 vs. 3.6%, P = 0.6) and reoperation for bleeding (0.5 vs. 0.6%, P = 0.8) were similar between groups. Study period was not associated with hematoma risk (odds ratio 0.87, 95% confidence interval 0.56–1.35, P = 0.5). Among survey respondents (41%), nonopioid analgesic consumption did not increase after opioids were removed from the discharge regimen (median, 6 pills/group, P = 0.06). Conclusions NSAIDs are associated with a low risk of hematoma after lumpectomy and SLNB, and should be prescribed instead of opioids, unless contraindicated.
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Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Regina Matar
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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10
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Patel AR, Vuong B, Kuehner GE, Odele P, Low G, Savitz A, Shim V, Mentakis M, Linehan E, Chang SB. Adoption of Opioid-Sparing and Non-Opioid Regimens After Breast Surgery in a Large, Integrated Health Care Delivery System. Ann Surg Oncol 2020; 27:4835-4843. [DOI: 10.1245/s10434-020-08897-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
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11
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Decreasing Opioid Prescriptions in Women Undergoing Mastectomy and Breast Reconstruction. Pain Manag Nurs 2020; 21:339-344. [PMID: 32280011 DOI: 10.1016/j.pmn.2020.02.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/12/2020] [Accepted: 02/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Florida enacted legislation limiting opioid prescriptions and affecting the management of acute pain in the postoperative patient. Patients in a reconstructive surgery practice were receiving prescriptions for opioids as their primary method of pain management. Clinic providers identified a need to limit opioid prescriptions. AIM The aim of this quality improvement initiative was to decrease the number of opioids prescribed while effectively managing pain in women undergoing mastectomy and breast tissue expander placement. DESIGN This is a quality improvement project. METHODS The Model for Improvement was used as a framework for this project. An evidence-based pain management plan was developed after a review of the breast reconstruction surgery literature. The plan incorporated preoperative patient and family education and the standard use of preemptive analgesia, intraoperative nerve blocks, and postoperative multimodal analgesia in all patients undergoing mastectomy with breast tissue expander placement. Patient and family education and perioperative pain management were provided to patients, and the number of opioid tablets prescribed was tracked. RESULTS Between January 2018 and August 2019, the average number of opioid tablets prescribed per patient decreased from 84.7 to 8.4. CONCLUSIONS Opioid prescriptions can be decreased in women undergoing breast reconstruction with the use of patient education and multimodal analgesia.
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Egan KG, De Souza M, Muenks E, Nazir N, Korentager R. Opioid Consumption Following Breast Surgery Decreases with a Brief Educational Intervention: A Randomized, Controlled Trial. Ann Surg Oncol 2020; 27:3156-3162. [DOI: 10.1245/s10434-020-08432-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Indexed: 12/16/2022]
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Brown G. Intendance des opioïdes : Passer du « pourquoi » au « comment “. Can J Hosp Pharm 2020; 73:5-6. [PMID: 32109954 PMCID: PMC7023918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Glen Brown
- , PharmD, FCSHP, BCPS(AQ), BCCCP, travaille à la pharmacie de l'Hôpital St Paul à Vancouver (Colombie-Britannique). Il est également rédacteur adjoint du Journal canadien de la pharmacie hospitalière
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Brown G. Opioid Stewardship: Moving Beyond the "Why" to the "How". Can J Hosp Pharm 2020; 73:3-4. [PMID: 32109953 PMCID: PMC7023919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Glen Brown
- , PharmD, FCSHP, BCPS(AQ), BCCCP, is with the Pharmacy, St Paul's Hospital, Vancouver, British Columbia. He is also an Associate Editor with the Canadian Journal of Hospital Pharmacy
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Maciver AH, Hartford LB. ASO Author Reflections: Multimodal Strategy Controls Pain and Reduces Opioid Prescription in Outpatient Breast Surgery. Ann Surg Oncol 2019; 26:824-825. [PMID: 31667720 DOI: 10.1245/s10434-019-07960-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Allison H Maciver
- Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. .,Division of Surgical Oncology, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
| | - Luke B Hartford
- Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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