An 89% drop in opioid use with restrictive prescribing protocol

The amount of opioids prescribed after gynecologic surgery declined by almost 90% with few complaints from patients after implementation of a restrictive prescription protocol, as reported here at the Society of Gynecologic Oncology (SGO) meeting.

Over a 6-month period, the total opioid pill count declined by 89% as compared with historical prescribing practices. The total included a 73% reduction the number of pills dispensed after open surgery and 97% after minimally invasive procedures.

Patients undergoing ambulatory/minimally invasive procedures and with no history of chronic pain received only prescription-strength ibuprofen or acetaminophen at discharge. Those with a history of opioid exposure or chronic pain, received a 3-day supply (12 pills) of hydrocodone-acetaminophen (Norco) or oxycodone-acetaminophen (Percocet).

Patients undergoing open surgery received either nonopioid pain medication or a 3-day opioid prescription at discharge. If a patient used an opioid for pain in the previous 24 hours, then a 3-day supply consisting of 24 pills (two every 6 hours) was prescribed.

More than 90% of patients went home without an opioid prescription after minimally invasive procedures, and fewer than 5% of patients expressed dissatisfaction with their doctors’ prescribing practices under the restrictive prescribing protocol, said Jaron D. Mark, MD, of the Roswell Park Comprehensive Cancer Center in Buffalo, New York.

“We were quite surprised by how few inquiries and requests for medication we got from our patients,” said Mark. “We expected that we would be able to reduce use of opioids without detrimental consequences, but the extent to which our hypothesis was supported by these results was really striking.”

Principal investigator Emese Zsiros, MD, PhD, also of Roswell Park, said the key factor in reducing opioid use after gynecologic surgery was setting appropriate expectations about pain management in advance of surgery — for clinicians and patients.

A second study reported at SGO documented overprescribing of opioids for minimally invasive hysterectomy. Patients routinely went home with an opioid prescription, but almost a third used none of the pills. The vast majority of patients used only a portion of the prescription, reported Erica Weston, MD, of Johns Hopkins Hospital in Baltimore.

Data, Planning, Caution

Taken together, the two studies showed that most patients undergoing gynecologic surgery — open or minimally invasive — require little or no opioid medication, said invited discussant Sean C. Dowdy, MD, of the Mayo Clinic in Rochester, Minnesota. Availability and use of nonopioid alternatives and preoperative education of patients are critical elements in a strategy to reduce opioid use.

Dowdy called for the development of procedure-specific guidelines for opioid use, which he helped develop at Mayo and will describe in detail at an upcoming meeting. Noting the lack of guidance in the medical literature, Dowdy and colleagues reviewed historical data encompassing 2,500 patients, 25 procedures, and 10 subspecialties. They then performed a survey of outpatient opioid prescribing practices covering a similar number of patients, procedures, and subspecialties.

After reviewing the data, surgeons at Mayo implemented a restrictive prescribing protocol similar to the one described by Mark. Dowdy said they expect to cut opioid use by 1.5 million pills a year.

However, he cautioned against allowing the prescription pendulum to swing too far in the direction of restrictive practices.

“There is no question that our current state is overprescribing, but we need to be very careful not to overcompensate and move to a state of underprescribing,” said Dowdy. “These guidelines apply to acute, postsurgical pain. They do not apply to management of chronic pain and certainly not apply to patients in the palliative-care setting.

‘Ultra-Restrictive’

Prior to implementing the restrictive protocol, Mark and colleagues surveyed U.S. gynecologic surgeons about their opioid prescribing practices. For patients undergoing minimally invasive procedures, half the surgeons prescribed 15-20 opioid tablets at discharge, and another 28% wrote prescriptions for 21 to 40 pills. For patients undergoing open surgery, two thirds of surgeons prescribed 21-40 opioid tablets and discharge, and 13% prescribed more than 40 tablets.

The restrictive protocol was evaluated from June 2017 through January 2018 and included 337 patients. Investigators compared the results with a control group of 626 patients who underwent similar procedures in prior years.

Overall, the average number of opioid tablets prescribed at discharge declined from 31.7 to 3.5, an 89% reduction. The total reduction included a 73% decline in average pill count for patients who had open surgery (43.6 vs 11.6, P<0.001) and a 97% decrease among patients undergoing minimally invasive procedures (28.1 vs 0.9, P<0.001). The proportion of patients discharged with no opioid prescription after minimally invasive procedures increased from 19.6% to 92.6% (P<0.001).

The average number of opioid tablets prescribed for patients with no prior opioid use declined from 31.7 to 3.1 (P<0.001) and from 31.6 to 6.2 among opioid-dependent patients (P<0.001).

The proportion of patients requesting refills within 30 days after surgery did not change significantly. Mean postoperative pain scores were virtually identical before and after implementation of the restrictive prescribing protocol (P=0.34).

Unused Pills

Weston reported findings from a prospective cohort study involving 114 women who underwent minimally invasive hysterectomy. The patients received an average of 3 opioid doses while in the hospital, and all were discharged with opioid prescriptions, averaging 30 pills per prescription. Weston said 25 patients used no opioid medication during hospitalization.

The women were surveyed regarding opioid use at follow-up visits 1-2 weeks after surgery and again at 4-6 weeks. At the first follow-up, 45 patients (36.9%) reported no opioid use since discharge, and the median number of pills used across the entire cohort was nine. At the end of follow-up, 37 patients (32.5%) had used no opioids, and the median number of pills since discharge was 11 for all 114 patients.

“We found that 90% of the patients used 30 or fewer opioid tablets,” said Weston. “The strongest predictor of opioid use after discharge was opioid use during the inpatient stay.”