‘Ultra-Restrictive’ Opioid Policy Post-Op: Benefits in Gyn Cancer

An “ultra-restrictive” policy to reduce opioid prescribing to women who underwent major gynecologic cancer surgeries dramatically reduced opioid use, according to a prospective, single-institution study presented at the 2018 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer, held March 24–27 in New Orleans, Louisiana.

“[I]mplementation decreased the number of opioid tablets prescribed by 73% for open [-surgery] cases and up to 97% for minimally invasive surgery and ambulatory cases,” reported Jason E. Mark, MD, of the Roswell Park Comprehensive Cancer Center in Buffalo, New York. “We observed no difference in postoperative pain scores and patient satisfaction.”

More than 170 Americans die of opioid overdoses each day, Dr. Mark reported. “The USA accounts for 4% of the world’s population but consumes about 30% of the total opioids,” Dr. Mark noted, adding that prescribing opioids even for relatively minor pain following surgical procedures is “routine practice.”

Nationwide, more than 78% of patients are prescribed 11 or more opioid tablets following minimally invasive surgery. Each state has its own legislation for opioid prescribing for acute pain management. In New York, no more than a 7-day supply can be prescribed for acute pain. Many patients who have undergone minimally invasive surgery do not take the pills prescribed or refill prescriptions, Dr. Mark said.

The research team suspect that surgery-related opioid overprescribing increases the risk of chronic opioid use and diversion, contributing to the national epidemic in opioid addiction and overdose deaths.

“We hypothesized that postsurgical acute pain could be effectively managed by non-opioid pain medications while maintaining appropriate pain relief after hospital discharge,” Dr. Mark said. The researchers sought to determine if patients are satisfied with dramatically smaller opioid prescriptions, or no prescriptions.

For patients undergoing minimally invasive surgery or ambulatory surgery, including all robotic, laparoscopic, and vulvar surgeries, the authors’ ultra-opioid-restrictive pain management protocol involved prescribing a 7-day supply of ibuprofen (600 mg Motrin) or acetaminophen (500 mg Tylenol) or, for patients with a history of chronic pain currently managed with opioids, limited 3-day prescriptions for opioid pain medications (Norco or Percocet).

The protocol was used to guide pain medication prescribing to all 337 gynecologic oncology patients who underwent surgery between June 2017 and January 2018. Prescribing data for 626 patients treated in prior years were served as control-group data for the analysis.

For all patients, the policy led to an 89% reduction in postsurgical opioid prescribing (P < .001) and a 97% reduction in the number of opioid tablets dispensed on discharge following minimally invasive and ambulatory cases (P < .001), Dr. Mark reported. The average number of prescribed opioid tablets declined from 31.7 to 3.5 per patient.

The proportion of patients discharged with no opioid medication climbed from 19.6% before the ultra-restrictive prescribing policy to 92.6% under the new policy, Dr. Mark said.

More than 95% of physicians reported patient satisfaction with the prescribing policy.

“Implementation of the ultra-restrictive opioid prescribing policy also decreased the opioids dispensed in chronic opioid use patients by 83%, and opioid refills remained low,” Dr. Mark said.