Changing from routinely prescribing opioids for patients who were having a lumpectomy or excisional biopsy to instead routinely prescribing nonsteroidal anti-inflammatory drugs [NSAIDs] resulted in a sharply decreased opioid prescription rate with “no difference in the proportion of patients reporting moderate or severe pain,” Tracy-Ann Moo, MD, a surgical oncologist at Memorial Sloan Kettering Cancer Center (MSK), New York, reported at the 22nd Annual Lynn Sage Breast Cancer Symposium.1
The investigators hypothesized that patients who were having a lumpectomy and sentinel lymph node biopsy could also be routinely discharged with NSAIDs at a similar rate, without needing subsequent opioids for pain control. Testing that hypothesis resulted in “a 78% absolute reduction in our opioid prescription rate,” she noted, which “translated into 19,500 fewer opioid pills that were dispensed annually.”
Tracy-Ann Moo, MD
According to Dr. Moo, the two MSK studies demonstrated that routine discharge with opioids may not be warranted for patients having an excisional biopsy or a lumpectomy, regardless of whether sentinel node biopsy is performed.
Enhanced Recovery After Surgery Protocols
These changes were enacted as part of an effort to reduce or eliminate opioid prescriptions for certain ambulatory breast surgery procedures and to build on Enhanced Recovery After Surgery (ERAS) protocols. These protocols “have been shown across multiple surgical specialties to improve patient outcomes, including reducing opioid consumption, postoperative nausea and vomiting, and hospital length of stay, and they provide a good framework within which we can think about reducing perioperative as well as discharge opioids in breast surgery,” Dr. Moo said.
Key components of this approach include patient education, using prophylaxis for postoperative nausea and vomiting, and a multimodal analgesia that uses “a combination of medications with different mechanisms of action to produce better pain relief with fewer side effects than would be seen with simply using higher doses of a single agent,” Dr. Moo explained. “Medications that form the core of this approach are perioperative gabapentin, acetaminophen, NSAIDs, and local anesthetics used as regional or local blocks, all of which work to minimize narcotic requirement in the postoperative period.”
Reducing Opioids After Lumpectomy or Excisional Biopsy
As part of a quality improvement initiative at MSK, “starting in August 2018, we no long prescribed opioids for patients having an excisional biopsy or a lumpectomy without an axillary procedure,” Dr. Moo recounted. “Instead, we sent these patients home with the NSAID diclofenac,” with exceptions for patients who had NSAID contraindications. These changes were formalized in discharge order sets.
“Roughly 9 months after implementing these changes, we performed a retrospective study,” Dr. Moo said. “We specifically looked at our opioid prescription rate after the switch from routine discharge with opioids to NSAIDs, and the NSAID failure rate, which was defined as the number of patients discharged with an NSAID who were prescribed an opioid for pain control within 7 days of the procedure.” Patient-reported pain scores were also compared.
Of 789 patients responding, 328 were treated when opioids were routinely prescribed at discharge and 461 after the switch to NSAIDs. “There were no differences in the two study periods in terms of demographic characteristics. Similarly, with respect to intraoperative management, the two study periods were comparable, with the exception of intraoperative acetaminophen administration, which was higher in the NSAID period,” Dr. Moo reported.
“[The study resulted in] a 78% absolute reduction in our opioid prescription rate, [which] translated into 19,500 fewer opioid pills that were dispensed annually.”— Tracy-Ann Moo, MD
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“The opioid prescription rate went from 96% in the opioid period to 14% in the NSAID period. Only five patients required an opioid prescription for pain control after being discharged with an NSAID, yielding a failure rate of 1%,” Dr. Moo noted. Most patients had no or mild pain, and very few reported severe pain. “The proportion of patients at risk of experiencing moderate or severe pain decreased from postoperative days 1 to 5, and there were no differences in the probability of experiencing moderate or severe pain between the two study periods, with a P value of .5,” Dr. Moo said.
Similar Results With Lumpectomy and Sentinel Node Biopsy
“Based on these results, we hypothesized that patients who were having a lumpectomy and sentinel node biopsy could also be routinely discharged without opioids, with a similarly low failure rate,” Dr. Moo stated.
Of the 663 patients in this study, 371 had been treated during the period in which patients continued to receive opioids in addition to NSAIDS at the time of discharge, and 292 patients had been treated during the period when routine opioids were eliminated. In the latter period, patients were “sent…home with an NSAID and instructions to use acetaminophen over the counter every 6 hours as needed. Again, exceptions were made for patients with medical contraindications to NSAIDs or for those whose patient care team recommended opioid prescription at discharge,”
Dr. Moo said.
The patients had comparable demographics and perioperative characteristics, and the “majority of both groups received intraoperative acetaminophen and ketorolac, indicating a consistent use of our ERAS protocol throughout the study,” Dr. Moo said.
“Opioid prescriptions decreased from 92% in the opioid period to 14% in the NSAID period,” Dr. Moo reported. This “represented a 78% absolute reduction in our opioid prescription rate, and, in our institution, we do approximately 2,500 of these cases a year. So, it translated into 19,500 fewer opioid pills that were dispensed annually. Only 5 of 251 patients who were initially discharged with an NSAID/acetaminophen regimen were later prescribed an opioid for pain control, yielding an overall failure rate of 2%.”
Even during the period when opioids were routinely prescribed, just 39% of patients used any, and “the median number taken by postoperative day 5 was only four tablets, confirming there is an overall low usage of opioids, even when we routinely prescribe them. In contrast, when we examined the number of NSAIDs or acetaminophen pills that had been taken, most patients in both study periods used NSAIDs or acetaminophen, with a median of five tablets being taken in the opioid period and six in the NSAID period.
"We found that for patients having an excisional biopsy or a lumpectomy, with or without a sentinel node biopsy, routine discharge with opioids was not warranted."— Tracy-Ann Moo, MD
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During postoperative days 1 to 5, “there was no significant difference in the maximum pain scores between the opioid vs NSAIDs study periods, with a P value of .7. Distribution of pain scores were comparable between the two groups, with most patients in both periods reporting no pain or mild pain,”
Dr. Moo stated.
NSAID/Acetaminophen Combination: Replacement for Routine Opioids?
To summarize, “In these two studies, we found that for patients having an excisional biopsy or a lumpectomy, with or without a sentinel node biopsy, routine discharge with opioids was not warranted. The NSAID/acetaminophen failure rate was quite low, between 1% and 2%, and most patients who were prescribed opioids didn’t actually use them. There were also no differences in the maximum reported pain scores among patients who were discharged with or without an opioid prescription,” Dr. Moo concluded.
“We would recommend the combination of NSAIDs with acetaminophen, as this has shown low failure rates in our group.”
DISCLOSURE: Dr. Moo reported no conflicts of interest.
1. Moo TA: New approaches to pain management in breast surgery. 2020 Lynn Sage Breast Cancer Symposium. Presented September 10, 2020.