Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management—American Society of Breast Surgeons Opioid/Pain Control Workgroup

Rao, Ruizhong; Rs, Jackson; Rosen, Brent R.; Brenin, David R.; Cornett, Wendy R.; Om, Fayanju; Sl, Chen; Golesorkhi, Negar; Ludwig, Kandice K.; Ma, Aiqun; Sk, Mautner; Sowden, Michelle; Wilke, Lee G.; Wexelman, Barbara; Blair, Sarah L.; Gary, Monique; Grobmyer, Stephen R.; Hwang, E. Shelley; James, Ted A.; Ns, Kapoor; Lewis, Jaime D.; Lizarraga, Ingrid M.; Miller, Max J.; Neuman, Heather B.; Showalter, Shayna L.; Smith, Linda J.; Froman, Joshua

doi:10.1245/s10434-020-08197-z

Cited by 26 publications

(15 citation statements)

References 22 publications

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“…The current study adds to our understanding of pain management requirements in this population. There is substantial variation in opioid usage, particularly in breast surgery, 18 where recent work illustrates that opioid prescribing continues to outpace consumption 19 , and guidelines aimed at optimizing multimodal pain regimens are very much needed 20 . Furthermore, our consumption data suggest that prescription sizes may be further reduced without compromising patient satisfaction.…”

Section: Discussionmentioning

confidence: 94%

Opioid prescribing exceeds consumption following common surgical oncology procedures

Eyrich

Sloss

Howard

et al. 2020

Journal of Surgical Oncology

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Background and Objectives: Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures. Methods: We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices. Results: Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them. Conclusions: This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.

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Section: Discussionmentioning

confidence: 94%

Opioid prescribing exceeds consumption following common surgical oncology procedures

Eyrich

Sloss

Howard

et al. 2020

Journal of Surgical Oncology

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“…A recent survey of 609 members of the American Society of Breast Surgeons found that approximately 80% of surgeons prescribed opioids after lumpectomy, with most prescribing a range of 1-10 tablets, and a minority prescribing > 31 tablets. 1 Despite this practice, there is no clear evidence that opioids are necessary for adequate pain control after lumpectomy/SLNB. An increasing number of studies suggest that non-opioid medications such as non-steroidal antiinflammatory drugs (NSAIDs) and/or acetaminophen can provide effective pain control after many commonly performed ambulatory procedures.…”

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confidence: 99%

Changing the Default: A Prospective Study of Reducing Discharge Opioid Prescription after Lumpectomy and Sentinel Node Biopsy

et al. 2020

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Background-Whether routinely prescribed opioids are necessary for pain control after discharge among lumpectomy/sentinel node biopsy (Lump/SLNB) patients is unclear. We hypothesized that Lump/SLNB patients could be discharged without opioids with a failure rate of <10%. This study prospectively examined outcomes after changing standard discharge prescription from an opioid/non-steroidal anti-inflammatory drug (NSAID) to NSAID/ acetaminophen.Methods-Standard discharge pain medication orders included opioids in the first 3-month study period and were changed to NSAID/acetaminophen in the second 3-month period. Patient-reported medication consumption and pain scores were collected by post-discharge survey. Frequency of discharge with opioid, NSAID/acetaminophen failure rate, opioid use, and pain scores were examined.Results-663 patients had Lump/SLNB from 05/2019-10/2019; 371 in the opioid study period and 292 in the NSAID period. In the opioid period, 92% (342/371) of patients were prescribed an opioid at discharge; of 142 patients who documented opioid use on the survey, 86 (61%) used 0 tablets. Among 56 (39%) patients who used opioids, the median number taken by POD5 was 4. After the change to NSAID/acetaminophen, rates of opioid prescription decreased to 14% (41/292). NSAID/acetaminophen failure rate was 2% (5/251). Among survey respondents, there was no significant difference in the maximum reported pain scores (POD 1-5) between the opioid versus NSAID period (p=0.7).

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“…Surgeons who avoid NSAIDs likely worry about hematoma formation, although the literature does not support this concern. [5][6][7] There was significant variability in the use of regional anesthesia for mastectomies with and without reconstruction despite its documented efficacy. [8][9][10][11][12][13] Thirty-three percent of surgeons reported never using nerve blocks for patients undergoing mastectomies with reconstruction, and 43% of surgeons did not use this analgesic strategy at all for patients undergoing mastectomies without reconstruction.…”

mentioning

confidence: 99%

“…The only procedures for which the workgroup recommends prescribing more than 10 tablets are ALND (20 or fewer tablets), mastectomy with or without axillary surgery (20 or fewer), and mastectomy with reconstruction (30 or fewer). 5 In addition to making these prescribing recommendations, the ASBrS workgroup encourages the use of regional anesthesia and strongly recommends the use of Enhanced Recovery After Surgery (ERAS) programs. Only a minority (14%) of respondents in this study reported using ERAS protocols.…”

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confidence: 99%

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Underutilization of Enhanced Recovery After Surgery (ERAS) in Breast Surgery: An Opportunity to Reduce Opioid Usage

Cyr

2020

Ann Surg Oncol

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Over a 20-year period, opioid-related deaths in the United States have increased sixfold. 1 In 2017, therefore, the Department of Health and Human Services officially declared this rapid increase in drug-related mortality a public health emergency. During that year, according to the Centers for Disease Control (CDC), more than 70,200 people died from drug overdoses; roughly 47,700 of those deaths involved opioids. Therefore, more people now die of opioid abuse or misuse annually than die of breast cancer. 2 Although this trend is multifactorial, a sharp increase in the number of opioid prescriptions is considered an important-and addressable-cause. 3 Despite the opioid crisis being a government and public health priority, the CDC offers little guidance for managing acute postsurgical pain. Although there are CDC pain management guidelines, they are written for primary care providers and make recommendations only for the treatment of chronic pain. 4 It has, therefore, been up to individual institutions and professional societies to create protocols for controlling surgical pain while addressing the new mandate to prevent opioid dependence. In this issue, Rao et al. 5 report the current breast and axillary surgery analgesia practices of members of the American Society of Breast Surgeons (ASBrS), and present the Society's perioperative pain control consensus statement. Roughly 20% of the 3000 ASBrS members who were invited to take the electronic survey responded. They were queried for methods of pain control used (local anesthesia, blocks, nonsteroidal anti-inflammatory drugs

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Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management—American Society of Breast Surgeons Opioid/Pain Control Workgroup

Abstract: is a part time employee for Avelas Biosciences-a company that develops imaging techniques to be used to identify margins during breast surgery. Dr. Lee Wilke is founder and minority stock owner for Elucent Medical-a tumor localization device company.

Cited by 26 publications

References 22 publications

Opioid prescribing exceeds consumption following common surgical oncology procedures

Opioid prescribing exceeds consumption following common surgical oncology procedures

Changing the Default: A Prospective Study of Reducing Discharge Opioid Prescription after Lumpectomy and Sentinel Node Biopsy

Underutilization of Enhanced Recovery After Surgery (ERAS) in Breast Surgery: An Opportunity to Reduce Opioid Usage

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