Eliminating Opioids from Breast Conserving Surgery: Perioperative Pain Management Pathway

Abstract

Opioid prescribing guidelines for partial mastectomy (PM) and PM with sentinel lymph node biopsy (PM-SLNB) recommend prescribing anywhere from 0 to 15 oxycodone pills for postoperative pain. We sought to eliminate opioids after breast-conserving surgery. In January 2017, we implemented a perioperative pathway in which patients received (1) preoperative acetaminophen, (2) pre-incisional bupivacaine skin infiltration, (3) post-excision bupivacaine wound deposition, (4) intraoperative ketorolac, (5) instructions to use both acetaminophen and ibuprofen for postoperative analgesia, and (6) counseling to set the expectation that opioids would not be required. We measured the percentage of patients who received, filled, and used opioid prescriptions. We compared this to historical institutional data from2016. There were 226 patients (mean age: 62 ± 13 years) who underwent surgery: 50% (114 of 226) underwent PM alone and 50% (112 of 226) PM-SLNB. Twenty-four patients (11%) required opioids in the recovery unit, and 14 (6%) were discharged home with a prescription. Five of the 14 patients (36%) did not fill their prescription. Among the patients who did fill their prescription, only 1 patient used opioids. In addition, 2 (1%) patients had difficulty managing their postoperative pain and were prescribed opioids within 7 days of surgery. Ultimately, 99% (223 of 226) of patients managed their postoperative pain after discharge without opioids. This represents a significant decrease in opioid use after breast conserving surgery, from 40% in 2016 to 1% after pathway implementation, p < 0.001. When a multimodal nonopioid pain pathway was implemented, 99% of patients undergoing breast-conserving surgery did not require opioids after discharge.