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The American Society of Breast Surgeons.
Annals of Surgical Oncology

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The Standardization of Outpatient Procedure (STOP) Narcotics: A Prospective Health Systems Intervention to Reduce Opioid Use in Ambulatory Breast Surgery

Luke B. Hartford DVM, MD, Julie Ann M. Van Koughnett MD, MEd, FRCSC, FACS, Patrick B. Murphy MD, MSc, MPH, FRCSC, Sarah A. Knowles MD, MSc, FRCSC, Robin B. Wigen MD, Laura J. Allen MSc, Collin F. M. Clarke MD, FRCPC, Muriel Brackstone MD, MSc, PhD, FRCSC, Daryl K. Gray MD, FRCSC, FACS, Allison H. Maciver MD, MSc, FRCSC
Breast Oncology
Volume 26, Issue 10 / October , 2019

Abstract

Background

During the past 15 years, opioid-related overdose death rates for women have increased 471%. Many surgeons provide opioid prescriptions well in excess of what patients actually use. This study assessed a health systems intervention to control pain adequately while reducing opioid prescriptions in ambulatory breast surgery.

Methods

This prospective non-inferiority study included women 18–75 years of age undergoing elective ambulatory general surgical breast procedures. Pre- and postintervention groups were compared, separated by implementation of a multi-pronged, opioid-sparing strategy consisting of patient education, health care provider education and perioperative multimodal analgesic strategies. The primary outcome was average pain during the first 7 postoperative days on a numeric rating scale of 0–10. The secondary outcomes included medication use and prescription renewals.

Results

The average pain during the first 7 postoperative days was non-inferior in the postintervention group despite a significant decrease in median oral morphine equivalents (OMEs) prescribed (2.0/10 [100 OMEs] pre-intervention vs 2.1/10 [50 OMEs] post-intervention; p = 0.40 [p < 0.001]). Only 39 (44%) of the 88 patients in the post-intervention group filled their rescue opioid prescription, and 8 (9%) of the 88 patients reported needing an opioid for additional pain not controlled with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) postoperatively. Prescription renewals did not change.

Conclusion

A standardized pain care bundle was effective in minimizing and even eliminating opioid use after elective ambulatory breast surgery while adequately controlling postoperative pain. The Standardization of Outpatient Procedure Narcotics (STOP Narcotics) initiative decreases unnecessary and unused opioid medication and may decrease risk of persistent opioid use. This initiative provides a framework for future analgesia guidelines in ambulatory breast surgery.

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