Analgesic Use Following Bilateral Breast Reduction

Abstract

The opioid epidemic in the United States resulted in 42,000 deaths in 2016, 40% of which involved a prescription opioid. It is estimated that 2 million patients become opioid-dependent after elective, ambulatory surgery each year. There has been increased interest in quantifying the need for postoperative narcotic pain medications for a variety of surgical procedures. However, studies have been limited. We sought to quantify the analgesic usage after one of the most common operations performed in plastic surgery, bilateral breast reduction. In this prospective, observational study, sequential breast reduction patients were contacted by telephone on the evening of postoperative days 3 and 7. Patients were queried as to which analgesic medications were used on the day of the phone call. Data relating to dosage, frequency, and satisfaction with pain control were sought. Patients taking chronic narcotics, postoperative complications requiring surgical intervention, and those unable to be reached after multiple attempts were excluded. Complete data were obtained for 40 patients. Narcotic prescriptions were written for oxycodone, hydromorphone and tramadol, with the number prescribed ranging from 0 to 20 tablets. The median total number used was 6 tablets. Eighty percent of patients used a total of 10 tablets or less. Fifty percent of patients were using only nonnarcotic analgesia by postoperative day 3. Patient-reported satisfaction with pain control was overwhelmingly positive, with 95% being either somewhat satisfied or very satisfied with postoperative pain control. Of those taking any medication on postoperative day 3, only half were using a nonsteroidal anti-inflammatory drug (NSAID) as part of their pain regimen. The number of tablets prescribed after breast reduction surgery varies considerably, and there is no consensus regarding the appropriate number to prescribe. Currently, few patients use all the medication prescribed to them, indicating a high rate of overprescribing. The overwhelming majority are satisfied with their pain control. Most patients use less than 10 tablets of narcotic pain medication after surgery. Acetaminophen is widely used as an adjunct but NSAIDs remain underutilized. Based on these data, we recommend that breast reduction patient's pain is best managed with acetaminophen, NSAIDs, and expectation management.

Variability in Opioid Prescribing Among Plastic Surgery Residents After Bilateral Breast Reduction

“…In this study, plastic surgery residents were found to demonstrate wide variability in their opioid prescribing patterns after bilateral breast reduction surgery, with many prescriptions exceeding typical use after this operation. 22 Existing evidence for opioid consumption after bilateral breast reduction suggests variability in consumption as well with ranges from 6 to 17.5 tablets corresponding to approximately 45 to 131.3 MME. 22,23 Typical prescriptions range from 0 to 20 tablets.…”

“…22,23 Typical prescriptions range from 0 to 20 tablets. 22 There is robust evidence that safe opioid titration should take into consideration patient age, risk of abuse, history of mental illness or addiction, and weight. [26][27][28][29] However, none of these factors were found to be predictive of opioid prescribing in this study.…”

“…Opioid overprescribing among plastic surgery providers after breast reductions has been elucidated previously. 17,22,24 However, this operation and other breast operations have been extensively studied in the context of opioid-free analgesic regimens with satisfactory patient outcomes. 39,40 The present study found that only 10 of 126 patients were sent home on opioid-free analgesia, whereas nonopioid analgesia recommendations were inconsistent.…”

“…This study was designed to characterize the prescribing patterns of plastic surgery residents and therefore did not include a quantification of opioid consumption by patients after breast reduction, which has been previously described. [22][23][24] As recommended by the Centers for Disease Control and Prevention, opioid prescriptions at discharge were converted into morphine milligram equivalents (MME) using a standardized conversion formula 25 : total MME = dosage  doses prescribed  MME conversion factor. Because of New York State restrictions, the state opioid prescribing database could not be accessed retrospectively to identify all concomitant opioid prescriptions in the patients studied.…”

An Education Intervention to Raise Awareness Reduces Self-reported Opioid Overprescribing by Plastic Surgery Residents

“… 17 However, we believe that preoperative opioid-related patient counseling provides a unique opportunity to engage with patients about their history of opioid use and to manage expectations about postoperative pain management. Recently, Fisher et al 46 surveyed bilateral breast reduction patients postoperatively and found that most patients had only used a small fraction of the tablets prescribed. As a result of their study, they have eliminated postoperative opioid analgesia for this patient population, choosing instead to counsel patients, preoperatively, that pain will be managed with acetaminophen and ibuprofen rather than prescription opioids.…”