Reassessing Opioid Use in Breast Surgery

Abstract

BackgroundThis study aims to assess multimodal pain management and opioid prescribing practices in patients undergoing breast surgery. MethodsA retrospective review of patients undergoing breast surgery at an academic medical center between April 1, 2018 and September 30, 2019, was performed. Patients with a history of recent opioid use or conditions precluding use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) were excluded. Opioid-sparing pain regimens were assessed. Opioids prescribed on discharge were recorded as oral morphine equivalents (OMEs) and concordance with the Opioid Prescribing Engagement Network (OPEN) determined. ResultsThe total study population consisted of 518 patients. 358 patients underwent minor outpatient procedures (sentinel lymph node biopsy, lumpectomy, and excisional biopsy), 10-40% of whom were appropriately prescribed as per the OPEN. Perioperatively, 53.9% of patients received APAP, 24.6% NSAIDs, 20.4% gabapentin, and 0.3% blocks; intraoperatively, 95.8% received local anesthetic and 25.7% ketorolac. For mastectomy without reconstruction, 63-88% of prescriptions were concordant with the OPEN. For mastectomy with reconstruction, discharge opioids ranged from 25 to 400 OMEs with a mean of 134.4 OMEs; 25% of patients received a refill. Of all patients undergoing mastectomy ± reconstruction, 62.5% received APAP, 18.8% NSAIDs, 38.8% pregabalin, and 20.6% locoregional block perioperatively; 37.5% received local anesthetic and 15.6% ketorolac intraoperatively. Of 143 inpatient stays, 89% received APAP, 38% NSAID, and 29% benzodiazepines; 29 patients received no opioids inpatient but were still prescribed 25-200 OMEs on discharge. ConclusionsThere is need for a multidisciplinary approach to pain management with the use of enhanced recovery after surgery protocols as potential means to standardize perioperative regimens and mitigate opioid overprescription.