Radical Opioid Restriction Works for Postoperative Patients

Pam Harrison

March 22, 2019

HONOLULU — An ultrarestrictive opioid prescribing protocol (UROPP) radically reduces the need for opioids following gynecologic oncology surgery without affecting pain scores, medication refill requests or the risk of complications, a retrospective analysis suggests.

"We are beginning to learn how patients become addicted to opioids…and we now understand that 80% of the 5% to 6% of patients who become chronic opioid users get addicted to opioids that started with a surgical prescription for them," Emese Zsiros, MD, PhD, assistant professor of oncology, Roswell Park Comprehensive Cancer Center in Buffalo, New York told Medscape Medical News.

"At our cancer center at Roswell Park, we have gone 'live' with every single surgical service, streamlining the opioid prescribing protocol for all types of surgeries, including head and neck, cardiothoracic, and surgical oncology, and we are hoping that over the next 6 months, we will be able to generate enough data across all surgical services to be able to shift and change policy prescribing practices," she added.

The study was reported here at the Society of Gynecologic Oncology (SGO) Annual Meeting 2019.

It was presented by colleague Jaron Mark, MD, gynecologic fellow, also of the Roswell Park Comprehensive Cancer Center. The team looked at opioid prescribing practices in the year prior to implementing the UROPP, and compared them with the dispensing practices seen in the year after which the UROPP was implemented in their own cancer center.

Some 604 patients were managed under the new opioid-sparing protocol; 626 patients were managed prior to its implementation and served as controls.

"The UROPP meant that all patients who had minimally invasive surgery, including robotic or laparoscopic surgery, were not sent home with an opioid prescription," Zsiros explained.

Patients who had additional major surgery requiring larger incisions — and from which they were not likely to recover as quickly — were sent home with either a 3-day supply of opioids (12 tablets) or a maximum of 24 tablets to cover them for their first week after surgery, including the days spent recovering in hospital.

Once the protocol was implemented, researchers collected data and compared it to the previous year when opioid prescriptions were not limited at the facility.

Reduction in Opioids

With the UROPP in place, there was a 73% reduction in the use of dispensed opioids in opioid-naïve patients who had undergone a standard laparotomy procedure compared with the protocol not being in place (P < .001).

In debulking cases, there was a 75% reduction in dispensed opioids post-UROPP compared with the non-opioid-sparing interlude (P < .001) and there was a 97% reduction in dispensed opioids in minimally invasive cases during the UROPP interval compared with the non-UROPP interval (P < .001), the researchers reported.

Analyzed by pill count, the drop in prescribed opioids under the ultrarestrictive protocol compared with the previous year was truly impressive:

  • 11.9 tablets vs 44.7 tablets for standard laparotomy patients

  • 10.2 tablets vs 41.9 tablets for debulking cases

  • 1.2 tablets vs 38.3 tablets for minimally invasive cases

Researchers also reported that the mean perioperative oral morphine equivalent dose dropped to 64.3 mg in the year after the opioid-restricting protocol was in place, down from 339.4 mg in the earlier interval when the opioid-sparing strategy was not used, again for opioid-naive patients.

Interestingly, however, researchers also found that the same dramatic reduction in postoperative opioid restriction was feasible even among patients who were chronic opioid users prior to their surgery.

Furthermore, researchers saw no increase in the number of refill requests in the post-UROPP interval at 16.5% of patients compared with 16.6% in the pre-UROPP group.

Nor were there any differences in mean postoperative pain scores at 1.1 for the post-UROPP group vs 1.4 for the pre-UROPP group, or the number of complications at 4.8% in the post-UROPP group vs 6.7% in the pre-UROPP group.

"I think the general principle is applicable to every surgical specialty, meaning that they are all equally overprescribing compared to what is needed," Zsiros said.

I think the general principle is applicable to every surgical specialty. Dr Emese Zsiros

Indeed, the research team estimated that almost 80% of gynecologic oncologists who responded to an earlier survey largely overprescribe opioids to their postoperative patients, and about half indicated that they feared patient satisfaction would be compromised if they prescribed fewer opioids.

This problem is compounded by the reality that many patients given excessive amounts of opioids for postoperative pain may not use them all but they almost always keep them, often in medicine cabinets that may be accessible to children or to others visiting their home, where it is possible they will be misused or diverted.

"By not providing what is not needed for recovery protects children as well as the community," Zsiros suggested.

Successful Restriction

Asked by Medscape Medical News to comment on the study, session moderator Carolyn Lefkowits, MD, of the University of Colorado Hospital in Aurora, said the study is important.

This group's rate of success with its ultrarestrictive prescribing protocol shows that the medical community can safely and effectively reduce outpatient postoperative opioid use while providing adequate postoperative pain control, and also reduce the amount of unused opioids people often keep in their homes at the same time, she said.

"This is an important contribution to the literature regarding outpatient postoperative opioid use in gynecologic oncology that will help us continue to strive to balance control of pain with risks of opioids," Lefkowits said.

"And it is appropriate for us to have a more restrictive approach to opioid use for postoperative pain, which is acute pain, as compared to chronic cancer-related pain in patients with active disease," she added.

Zsiros, Mark, and Lefkowits have disclosed no relevant financial relationships.

Society of Gynecologic Oncology (SGO) Annual Meeting 2019: Abstract 27. Presented March 18, 2019.

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