Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery

Abstract

<h3>Objectives:</h3> Opioids are routinely prescribed for patients after surgery, with minimal data to inform the ideal dose. The aim of the study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents (MME) prescribed and to assess pain control in patients undergoing minimally invasive gynecologic oncology surgery. <h3>Methods:</h3> A restrictive opioid prescription protocol was implemented from January through September 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for malignancy were included. As part of the protocol, we implemented use of multimodal analgesia (acetaminophen and non-steroidal anti-inflammatory drugs (NSAID)), patient and provider education, pre-printed standardized opioid prescriptions and tracking of opioid prescriptions. Total opioid tablets prescribed and refill requests were compared to a historical cohort of 100 consecutive patients (2018-2019). Post-intervention, patients were surveyed regarding postoperative opioid use, pain control and overall experience. We performed a descriptive analysis of the characteristics of pre-post intervention cohorts. Chi-square and Fisher's exact tests were used for categorical variables and Wilcoxon Rank-Sum tests for continuous variables. <h3>Results:</h3> A total of 79 women in the post-intervention cohort were compared with 100 historical controls. The post-intervention cohort was younger (59 vs 65; p=0.04) however clinical and surgical characteristics were not statistically different between the groups. Following protocol implementation, MME prescribed decreased from 50 (range 9-100) to 25 (range 7.5-75) (p<0.001). Overall, 74% (59/79) used 10 MME or less and 41 patients (52%) used 0 MME. Multimodal analgesia including acetaminophen and NSAIDs was used in 85% of patients post-intervention compared to 73% in the historical cohort (p=0.069). There was no additional increase in opioid refill requests after implementation of our strategy. Overall, post-intervention, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery. <h3>Conclusions:</h3> Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery with over 50% of patients not requiring opioids postoperatively. This initiative was not met with added adverse consequences.