Large Opioid Decrease After Gynecologic Surgery With New Restrictive Protocol

Jaron E. Mark, MD

A prospective study found that implementing an “ultra-restrictive” opioid prescription protocol for gynecologic surgery had led to an 89% reduction in opioid tablets dispensed at discharge and a high rate of patient satisfaction.

For patients undergoing surgery, the amount of tablets dispensed at discharge decreased by 73% while there was a decrease of 97% for patients who had ambulatory or minimally invasive procedures. Over 90% of the patients who were 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.

Mark also added, “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.”

The routine practice for management of relatively minor pain and after minor surgery and procedures has always been opioid prescriptions, Mark noted. This practice has been “enshrined” in electronic health record systems prepopulating records with high amounts 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 has a limitation on opioid distribution for postoperative pain to no more than a 7-day supply. A recent survey by Mark and colleagues looked at opioid prescribing practices in the United States. Half of the respondents admitted to sending patients home with 11 to 20 opioid tablets after a minimally invasive surgery, and 28.3% said they had dispensed 21 to 40 tablets. When looking at patients undergoing open procedures, 66% of the gynecologic oncologists surveyed said they sent patients with 21 to 40 opioid tablets at discharge and 13.3% gave patients more than 40 tablets in this situation.

The hypothesises of this survery assumed 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.

Gynecologic surgeons at Roswell Park followed an ultra-restrictive opioid prescription protocol for the management of postoperative pain after surgery from June 2017 to January 2018.

Of the patients undergoing minimally invasive/ambulatory procedures with no history of chronic pain, surgeons prescribed 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 were given a 3-day prescription, opposing the state-allowed 7-day prescription. Patients undergoing a laparotomy were given a 3-day prescription of ibuprofen, acetaminophen, or an opioid if there was no history of chronic pain. All other patients received a 3-day opioid prescription in this study.

The restrictive prescription protocol included 337 patients for this study. Investigators examined data from records of 626 patients undergoing similar procedures in prior years to find comparisons.

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

Prior to implementation of the restrictive prescribing protocol, the review found that gynecologic surgeons dispensed an average of 31.7 opioid tablets to patients at discharge. This average declined by 89% with an average of 3.5 tablets after the protocol went into effect. The tablet count was reduced by a similar degree in cases of patients with a history of opioid-managed pain.

Analysis of open procedures discovered that the mean tablet count at discharge was reduced by 73% (P<.001), from 43.6 to 11.6 tablets. There was no significant difference in tablet count for procedures requiring debulking versus nondebulking (13.6 vs 11.2 tablets).

The mean opioid tablet count for patients undergoing minimally invasive procedures at discharge decreased from 28.1 to 0.9 with a 97% reduction rate (P<.001). There was an increase in proportion of patients who went home without an opioid prescription, from 19.6% to 92.6% (P<.001).

There was no significant different in the proportion of patients requesting opioid refills within 30 days of surgery, for patients undergoing open procedures (17.1% vs 13.6%,P= .34) or patients undergoing minimally invasive procedures (7.5% vs 7.8%;P= .88).

This study also found that prior to implementation of the restrictive protocol, 57.5% of gynecologic surgeons in the survery expected the satisfaction of their patients' care would decrease with the restrictive opioid prescribing protocol. Rather, 95.6% of the patients said they were satisfied with the surgeons&rsquo; prescribing practice. The study also found that those patients' mean postoperative pain score did not change with the new protocol (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.