Protocol Effects Big Drop in Opioid Use After Gynecologic Surgery

Jaron E. Mark, MD

Implementation of an “ultra-restrictive” opioid prescription protocol for gynecologic surgery led to an 89% reduction in the number of opioid tablets dispensed at discharge and a high rate of patient satisfaction, a prospective study showed.

The number of tablets dispensed at discharge decreased by 73% for patients undergoing open surgery and by 97% for those who had ambulatory or minimally invasive procedures. More than 90% of patients undergoing minimally invasive procedures were discharged with no opioid medication.

More than half of physicians participating in the program said their patients would be dissatisfied with the change, but when the 6-month study ended, 96% said their patients were satisfied with the prescribing practice, as reported at the 2018 Society of Gynecologic Oncology Annual Meeting.

“We hypothesized that surgeons overprescribe opioid pain medication in patients undergoing major and ambulatory surgeries, which increases the risk of chronic opioid use, abuse, and diversion,” said lead author Jaron E. Mark, MD, an oncology fellow at Roswell Park Comprehensive Cancer Center. “We observed no difference in postoperative pain scores and patient satisfaction. Implementation of an ultra-restrictive opioid prescription protocol decreased the opioids dispensed in chronic opioid—use patients by 83%, and opioid refills remained low.”

Opioid prescriptions have been routine practice even for management of relatively minor pain and after minor surgery and procedures, Mark noted in his introduction to the study. The practice is “enshrined” in electronic health record systems that prepopulate records with large numbers of tablets to save clinicians time.

“We all know it takes 30 seconds to tell a patient ‘yes’ to an opioid prescription but it takes 30 minutes to tell them ‘no,’” said Mark.

The State of New York limits opioid distribution for postoperative pain to no more than a 7-day supply. Mark and colleagues recently surveyed gynecologic oncologists in the United States regarding opioid prescribing practices. Half of the respondents said they sent patients home with 11 to 20 opioid tablets after minimally invasive surgery, and 28.3% dispensed 21 to 40 tablets. For patients undergoing open procedures, 66% of the gynecologic oncologists said they gave patients 21 to 40 opioid tablets at discharge and 13.3% gave patients more than 40 tablets.

Mark and colleagues hypothesized that gynecologic surgeons could effectively manage patients’ postoperative pain with nonopioid medications and that patients would be satisfied with fewer opioid tablets at discharge or none at all.

From June 2017 through January 2018, gynecologic surgeons at Roswell Park followed an ultra-restrictive opioid prescription protocol for management of postoperative pain. Patients who underwent minimally invasive/ambulatory procedures and had no history of chronic pain received a 7-day supply of prescription-strength ibuprofen or acetaminophen. Patients who required 5 or more pills/doses of opioids or who had a history of chronic pain requiring opioids received a 3-day prescription, as opposed to the state-allowed 7-day prescription.

Patients undergoing laparotomy received a 3-day prescription of ibuprofen, acetaminophen, or an opioid if they had no history of chronic pain. All others received a 3-day opioid prescription.

The study period for the restrictive prescription protocol included 337 patients. For comparison, investigators extracted data from records of 626 patients undergoing similar procedures in prior years.

A review of the “pre-protocol” group showed that 55.1% of patients had surgery for benign conditions and 44.9% for malignancy, and 41% of the malignancy procedures were staged. During the study period, 58.5% of procedures were for benign conditions, 41.5% for malignant conditions, and 39% of procedures for malignancy were staged.

The results showed that prior to implementation of the restrictive prescribing protocol, gynecologic surgeons dispensed an average of 31.7 opioid tablets to patients at discharge. That declined to an average of 3.5 tablets after the protocol went into effect, an 89% reduction. The tablet count decreased by a similar degree for patients who had a history of opioid-managed pain and those who did not.

An analysis of open procedures showed that the mean tablet count at discharge declined from 43.6 to 11.6, a 73% reduction (P <.001). The tablet count for procedures requiring debulking did not differ significantly from nondebulking procedures (13.6 vs 11.2 tablets).

For patients undergoing minimally invasive procedures, the mean opioid tablet count at discharge decreased from 28.1 to 0.9, a 97% reduction (P <.001). The proportion of patients who went home without an opioid prescription increased from 19.6% to 92.6% (P <.001).

The proportion of patients requesting opioid refills within 30 days of surgery did not change significantly for patients undergoing open procedures (17.1% vs 13.6%, P = .34) or minimally invasive procedures (7.5% vs 7.8%; P = .88).

Prior to implementation of the restrictive protocol, 57.5% of the participating gynecologic surgeons said their patients’ satisfaction with care would decrease with the restrictive opioid prescribing protocol. Instead, 95.6% of the patients said they were satisfied with the surgeons’ prescribing practice. Patients’ mean postoperative pain score did not change (a mean of 1 before and after implementation of the prescription protocol).

Mark JE, Phoenix D, Gutierrez CA, et al. Tackling the opioid crisis: implementation of an ultra-restrictive opioid prescription protocol in patients undergoing major gynecologic surgery radically decreased dispensed opioid without reducing pain control. Presented at: SGO Annual Meeting; March 24-27, 2018; New Orleans, LA. Abstract 7.

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