Decreasing opioid use in postoperative gynecologic oncology patients through a restrictive opioid prescribing algorithm

Evidence-based prescribing of opioids after laparotomy: A quality-improvement initiative in gynecologic oncology

Introduction

Across specialties, surgeons over-prescribe opioids to patients after surgery. We aimed to develop and implement an evidence-based calculator to inform post-discharge opioid prescription size for gynecologic oncology patients after laparotomy.

Methods

In 2021, open surgical gynecologic oncology patients were called 2-4 weeks after surgery to ask about their home opioid use. This data was used to develop a calculator for post-discharge opioid prescription size using two factors: 1) age of the patient, 2) oral morphine equivalents (OME) used by patients the day before hospital discharge. The calculator was implemented on the inpatient service from 8/21/22 and patients were contacted 2-4 weeks after surgery to again assess their opioid use at home.

Results

Data from 95 surveys were used to develop the opioid prescription size calculator and are compared to 95 post-intervention surveys. There was no difference pre- to post-intervention in demographic data, surgical procedure, or immediate postoperative recovery. The median opioid prescription size decreased from 150 to 37.5 OME (p < 0.01) and self-reported use of opioids at home decreased from 22.5 to 7.5 OME (p = 0.05). The refill rate did not differ (12.6 % pre- and 11.6 % post-intervention, p = 0.82). The surplus of opioids our patients reported having at home decreased from 1264 doses of 5 mg oxycodone tabs in the pre-intervention cohort, to 490 doses in the post-intervention cohort, a 61 % reduction.

Conclusions

An evidence-based approach for prescribing opioids to patients after laparotomy decreased the surplus of opioids we introduced into our patients' communities without impacting refill rates.

Developing and Implementing a Patient-Centered Opioid Prescribing Algorithm among Gynecological Oncology Patients

Background: The opioid epidemic is a public health crisis. However, opioid prescription recommendations have not been established in gynecological oncology, and guidelines that incorporate patient-reported pain are lacking. Objectives: The article aims to evaluate prescribing patterns, utilization, and patient-reported pain control in gynecological oncology patients at a large tertiary academic center. Methods: This was a two-phase, prospective cohort study. For Phase 1, patients undergoing hysterectomy through the gynecological oncology division at the University of New Mexico were enrolled. Postoperative opioid use was collected and standardized to oral morphine milligram equivalents (MMEs). The factors associated with outpatient opioid use were used to develop an opioid prescription algorithm. In Phase 2, we evaluated the implementation of the prescription algorithm. For both phases, patients completed a demographic survey, satisfaction survey, and validated pain questionnaires. Results: In Phase 1, the amount of opioids used was significantly lower than the amount of opioids prescribed. Factors that correlated with postoperative opioid use included surgical procedures and last 24-hour inpatient MME use. A standardized opioid prescription algorithm was developed by incorporating these factors. In Phase 2, the opioid prescribing algorithm there was no significant difference in pain scores between the two phases. Conclusions: Opioids were substantially overprescribed in gynecological oncology patients undergoing hysterectomy. Our study found that the surgical route and last 24-hour MME inpatient usage were reliable predictors of outpatient opioid use. We developed and implemented a standardized opioid prescription algorithm that was validated by comparing the pain control measures in the two phases.

A "just in time" educational intervention for opioid overprescribing in dialysis access surgery

BACKGROUND

Despite widespread efforts to combat the opioid epidemic, an ongoing contributor to opioid misuse remains post-operative opioid overprescribing by residents. The goal of this study was to evaluate the impact of a low-cost, reproducible "just in time" intervention on opioid prescribing in dialysis access operations.

METHODS

Standardized opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. Wilcoxon rank-sum test and tests of proportions were used to compare groups.

RESULTS

Overall, 299 patients underwent dialysis access procedures. There was a decrease in patients discharged with opioids following the intervention from 58% to 36% (p ​= ​0.003). For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents (p ​= ​0.03).

CONCLUSIONS

This low-cost and timely learning intervention may be a useful adjunct to reduce post-operative opioid prescriptions.

Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement

BACKGROUND

Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription.

OBJECTIVE

To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education.

METHODS

We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis.

RESULTS

The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99).

CONCLUSION

Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.

Enhanced Recovery after Surgery (ERAS) for Minimally Invasive Gynecologic Oncology Surgery: A Review

Enhanced recovery after surgery (ERAS) has established benefits in open gynecologic oncology surgery. However, the benefits for gynecologic oncology patients undergoing minimally invasive surgery (MIS) are less well defined. We conducted a review of this topic after a comprehensive search of the peer-reviewed literature using MEDLINE and PubMed databases. Our search yielded 25 articles, 14 of which were original research articles, in 10 distinct patient cohorts describing ERAS in minimally invasive gynecologic oncology surgery. Major benefits of ERAS in MIS included: decreased length of stay and increased rates of same-day discharge, cost-savings, decreased opioid use, and increased patient satisfaction. ERAS in minimally invasive gynecologic oncology surgery is an area of great promise for both patients and the healthcare system.

The past, present, and future of opioid prescribing: perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021

Objective

To describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates.

Methods

Part one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge.

Results

1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients.

Conclusion

Inpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients' actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.

Risk Factors for Postoperative Narcotic Use in Benign, Minimally-Invasive Gynecologic Surgery

Background and Objectives:

To evaluate postoperative opioid use after benign minimally-invasive gynecologic surgery and assess the impact of a patient educational intervention regarding proper opioid use/disposal.

Methods:

Educational pamphlets were provided preoperatively. Patients underwent hysterectomy, myomectomy, or other laparoscopic procedures. Opioid prescriptions were standardized with 25 tablets oxycodone 5mg for hysterectomy/myomectomy, 10 tablets oxycodone 5mg for LSC (oral morphine equivalents were maintained for alternatives). Pill diaries were reviewed and patient surveys completed during postoperative visits.

Results:

Of 106 consented patients, 65 (61%) completed their pill diaries. Median opioid use was 35 OME for hysterectomy (∼5 oxycodone tablets; IQR 11.25-102.5), 30 OME for myomectomy (∼4 tablets; IQR 15-75), and 18.75 OME for laparoscopy (∼3 tablets; IQR 7.5-48.75). Median last post-operative day (d) of use was 3d for hysterectomy (IQR 2, 8), 4d for myomectomy (IQR 1, 7), and 2d for laparoscopy (IQR 0.5-3.5). One patient (myomectomy) required a refill of 5mg oxycodone. No difference was found between total opioid use and presence of pelvic pain, chronic pain disorders, or psychiatric co-morbidities. Overall satisfaction with pain control (>4 on a 5-point Likert scale) was 91% for hysterectomy, 100% for myomectomy, 83% for laparoscopy. Of the 33 patients who read the pamphlet, 32(97%) felt it increased their awareness.

Conclusion:

Most patients required <10 oxycodone 5mg tablets, regardless of procedure with excellent patient satisfaction. A patient education pamphlet is a simple method to increase knowledge regarding the opioid epidemic and facilitate proper medication disposal.

Using an Environmentally Friendly Disposal Bag to Discard Leftover Opioids After Gynecologic Surgery

OBJECTIVE

To evaluate the effects of an environmentally friendly drug deactivation bag on opioid disposal among patients undergoing gynecologic surgery.

METHODS

This prospective cohort study included patients undergoing gynecologic procedures requiring an opioid prescription from March 2020 to December 2020. Patients were managed on a restrictive opioid prescribing algorithm and given an opioid disposal bag. The carbon drug deactivation bag neutralizes the opioid medication and can be discarded safely in the trash. Patients were educated about pain management goals and the disposal bag. Patients were surveyed at their postoperative visit to evaluate satisfaction, number of leftover pills, and disposal methods. Statistical analysis was performed using SPSS Statistics 26.

RESULTS

Two hundred patients were asked to complete the survey, with a response rate of 78%. The most common procedures were exploratory laparotomy (50%) and minimally invasive hysterectomy (41%). Most patients (91%, 95% CI 91-97) filled their opioid prescription and 64 (41%, 95% CI 34-48) had leftover opioid pills. Most patients with leftover opioid pills (73%, 95% CI 67-79) discarded them; 78%, 95% CI 69-80 used the disposal bag. Patients undergoing an exploratory laparotomy most commonly used the disposal bag. All patients who used the disposal bag stated they would use it again.

CONCLUSION

Despite a restrictive opioid prescribing algorithm, 41% of gynecologic surgical patients had leftover opioid pills. This study demonstrated that leftover opioid pills were safely discarded 73% of the time when patients were provided an opioid disposal bag and preoperative education.

Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery

OBJECTIVES

Opioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents prescribed and pain control in patients undergoing minimally invasive surgery.

METHODS

A restrictive opioid prescription protocol was implemented from January through December 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for suspected malignancy were included. Simultaneously, we implemented use of multimodal analgesia, patient and provider education, pre-printed standardized prescriptions, and tracking of opioid prescriptions. Total median morphine milligram equivalents prescribed were compared between pre- and post-intervention cohorts. Patients were surveyed regarding opioid use and pain control at 30 days post-surgery.

RESULTS

A total of 101 women in the post-intervention cohort were compared with 92 consecutive pre-intervention controls. Following protocol implementation, median morphine milligram equivalents prescribed decreased from 50 (range 9-100) to 25 (range 8-75) (p<0.001). In the post-intervention cohort, 75% (76/101) used 10 median morphine milligram equivalents or less and 55 patients (54%) used 0 median morphine milligram equivalent. There was no additional increase in opioid refill requests after implementation of our strategy. Overall, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery.

CONCLUSIONS

Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery, with over 50% of patients requiring no opioids postoperatively.

Optimization of postoperative opioid prescriptions in gynecologic oncology: Striking a balance between opioid reduction and pain control

OBJECTIVE

To implement a quality-improvement initiative to assess the impact various patient and procedural factors have on postoperative opioid use. To develop a tailored opioid prescribing algorithm for gynecologic oncology patients.

METHODS

A retrospective cohort study was performed of patients who underwent a laparoscopy or laparotomy procedure for a suspected or known gynecologic malignancy between 3/2019-9/2020. Patients were assessed preoperatively for the presence of suspected risk factors for opioid misuse (depression, anxiety, chronic pain, current opioid use, or substance abuse). Patients completed a 30-day postoperative questionnaire assessing for total opioid pill use and refills requests. Multivariate models were developed to estimate the independent effect of sociodemographic characteristics, risk factors for opioid misuse and procedural factors on patient reported postoperative opioid use.

RESULTS

A total of 390 patients were analyzed. Thirty-nine percent (N = 151/390) of patients reported not using opioids after discharge and 5% (N = 20/390) received an opioid refill. For both minimally invasive procedures and laparotomy procedures, body mass index, comorbidities, intraoperative or postoperative complications and final diagnosis of malignancy were not associated with the amount of opioid consumption. However, younger age and history of risk factors for opioid misuse significantly impacted postoperative opioid use. In multivariate analysis, age (p = 0.038) and risk factors (p < 0.001) remained significant after controlling for other factors.

CONCLUSIONS

Two out of every five patients did not use opioids after surgery. Younger patients and those with risk factors for opioid misuse need a tailored approach to prescribing opioids to balance the need for adequate pain control with the risk of misuse.