By Katherine Rivlin, MD, MSc
Assistant Professor, Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
Dr. Rivlin has no relevant financial relationships with ineligible companies to disclose.
SYNOPSIS: With sufficient institutional buy-in, appropriate patient education, and staff adherence to standardized postoperative prescribing practices, patients undergoing abdominal gynecologic surgery can leave the hospital safely and recover with low doses of opioid medications, or no opioid prescription at all.
SOURCE: Margolis B, Andriani L, Baumann K, et al. Safety and feasibility of discharge without an opioid prescription for patients undergoing gynecologic surgery. Obstet Gynecol 2020;136:1126-1134.
Patients with unused prescribed opioids and their household contacts are at a greater risk of opioid misuse than those without such opioids.1 A reduction in opioid prescriptions among postoperative patients could, therefore, go a long way in combating the opioid epidemic in the United States. This retrospective cohort study assesses the effect of a quality improvement (QI) intervention to reduce unnecessary opioid prescriptions in patients undergoing gynecologic surgery.
The QI intervention was introduced in June 2019 at NYU Langone Health, and aimed at all gynecologic oncology patients undergoing both laparotomy and minimally invasive abdominal and pelvic surgery. Six months into the intervention, the authors conducted a retrospective chart review comparing postintervention patients to a historical control cohort of patients from the six months leading up to the intervention. They excluded patients who underwent vulvar, vaginal, or hysteroscopic procedures, as well as patients whose surgery was performed in conjunction with another surgical service.
The intervention consisted of three primary pillars. The first pillar, preoperative patient counseling, included setting expectations for limited or no routine opioid prescriptions and describing strategies for minimizing pain without opioids. The second pillar incorporated standardized perioperative analgesia. In conjunction with an enhanced recovery pathway, all patients received perioperative acetaminophen and gabapentin; early feeding and ambulation; and postoperative opioid-sparing analgesia, including scheduled acetaminophen, ibuprofen, and gabapentin. The third pillar was a postoperative opioid prescription algorithm. Patients received discharge opioid prescriptions according to their opioid requirement during admission. Patients discharged on the same day as surgery received no opioid prescription.
The research team encouraged patients to call in after discharge to report poorly controlled pain and assured them that opioids would be prescribed as needed. The research team ensured compliance with the intervention’s protocol among nurses, house staff, and attending physicians by providing continued educational reinforcement. They performed a chart extraction from both cohorts to assess demographic information, procedure details, perioperative details and complications, preoperative and postoperative opioid prescriptions, and postoperative complications. Their primary outcome measurement was the percentage of patients discharged with an opioid prescription.
They analyzed 276 patients pre-intervention and 256 patients postintervention. The two cohorts were similar demographically, except that the pre-intervention group had more Caucasian patients (P = 0.046). The majority of surgeries in both cohorts were minimally invasive.
The percent of patients discharged with an opioid prescription decreased from 82.7% to 23.1% (P < 0.001) following the intervention. Of written opioid prescriptions, the mean number of tablets decreased from 7.2 tablets (standard deviation [SD] = 5.7) to 1.8 tablets (SD = 4.3) (P < 0.001). There was no difference in postoperative complications, phone calls for pain, opioid refills, or new opioid prescriptions after discharge between the two cohorts.
As much as 92% of patients have unused opioids following surgical recovery.2 Unused opioids have the potential to be stored and disposed of improperly and can lead to opioid abuse, and even overdose, among patients and patients’ household contacts. Hysterectomies are one of the most commonly performed surgical procedures for women in the United States, and reducing opioid prescriptions following this common procedure could greatly reduce the number of unused opioids in households across the United States.
This study documents tremendous efforts from the authors and their institution to implement a QI intervention aimed at reducing postoperative opioid prescription. Based on the results reported in this retrospective chart review, this effort was quite successful.
However, the article also makes clear the challenges of implementing such an intervention. This QI intervention required education and reeducation of the care team and support staff. The authors noted some “initial hesitation” among the staff to discharge patients without opioids, especially following laparotomy, since this was the most “novel” change from previous practice. Such change was only possible through a “shared mission” among all healthcare providers to reduce opioid prescriptions.
NYU already had implemented an enhanced recovery pathway, an intervention that has been shown to reduce opioid use following surgery.3,4 Since the hospital and staff had already been exposed to institution-wide perioperative changes, the intervention likely was integrated more easily into routine clinical practice.
Clinically, someone considering implementing such an intervention at their institution should learn the following from the authors’ experiences:
- Recognize the importance of buy-in at all levels of care, from the patient, to nursing, to house staff, to the institution at large.
- Educate, reeducate, and educate again. Continuously check with your team to assess protocol compliance and provide feedback and support where needed.
- Move in a stepwise fashion, rather than implementing drastic changes all at once. This will increase compliance at every level.
Several important limitations to this study warrant discussion. The authors used pain phone calls and phone calls that resulted in new or refilled opioid prescriptions as a proxy for inadequate pain control. They concluded that because the number of phone calls was the same pre- and postintervention, that pain control did not change with reduced opioid prescriptions.
Clinically, we know that some patients feel more empowered to call their care team than others, and an education intervention detailing the plan to reduce opioid prescriptions might have further dissuaded such patients. Therefore, phone calls are a poor proxy for adequate pain control. The study team surveyed some (but not all) patients on their perceptions of postoperative pain, and most patients felt “satisfied.” These pain surveys occurred at the two-week postoperative visit and, therefore, were subject to recall bias, a poor measure of pain. A more nuanced measure of pain control could have included daily pain diaries collected prospectively.
The authors also noted that, although the preintervention group had more Caucasian patients than the postintervention group, this difference was “not likely to affect outcome measures.” We know that among postpartum patients, Hispanic and non-Hispanic Black patients are less likely to be prescribed opioids at the time of discharge compared to non-Hispanic white patients.5 Although this question is unstudied in the gynecological oncology patient population, similar disparities in opioid prescribing practices have been well documented across multiple medical settings.6,7 The differences in demographics between the two cohorts, therefore, do warrant additional attention, since race could have played an important role in provider prescribing practices. Standardizing postoperative pain medication in an algorithm intended to reduce opioid prescriptions may have the unintended consequence of reducing racial disparities in prescribing practices as well and could pave the way to more equitable analgesia.
- Khan NF, Bateman BT, Landon JE, Gagne JJ. Association of opioid overdose with opioid prescriptions to family members. JAMA Intern Med 2019;179:1186-1192.
- Bicket MC, Long JJ, Pronovost PJ, et al. Prescription opioid analgesics commonly unused after surgery: A systematic review. JAMA Surg 2017;152:1066-1071.
- Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part I. Gynecol Oncol 2016;140:313-322.
- Weston E, Noel M, Douglas K, et al. The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy. Gynecol Oncol 2020;157:469-475.
- Badreldin N, Grobman WA, Yee LM. Racial disparities in postpartum pain management. Obstet Gynecol 2019;134:1147-1153.
- Ly DP. Racial and ethnic disparities in the evaluation and management of pain in the outpatient setting, 2006-2015. Pain Med 2019;20:223-232.
- Singhal A, Tien YY, Hsia RY. Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PLoS One 2016;11:e0159224.