Postoperative Pain Management without Opioids for Mastectomy and Reconstruction

The opioid epidemic is propelling surgeons to seek non-narcotic approaches for managing postoperative pain. Cleveland Clinic Breast Center is leading a quality control initiative that aims to improve safety and pain management by educating patients, collecting prescribing and usage data, improving non-opiate pain control and reducing opiate prescribing.

“We are excited about finding new ways to manage pain,” says Stephanie Valente, DO, Director of the Breast Surgery Fellowship Program at Cleveland Clinic. “Surgeons have an obligation to treat their patients’ postoperative pain, but also to follow appropriate prescribing behavior and avoid overprescribing. If we are effective at managing pain, patients won’t need as much pain medication.”

Extended-release bupivacaine

The initiative is focusing on pain control using multimodal analgesia, a critical component of enhanced recovery after surgery (ERAS) protocols. In recent years, ERAS protocols, which include preoperative optimization, prevention of surgical complications, reduction of physiological stress response to surgery and rehabilitation to normal function, have gained broad acceptance by many surgical specialties. Studies have found that ERAS protocols decrease length of stay (LOS), improve quality of care and reduce healthcare costs.

Multimodal analgesia uses different mechanisms to control pain, including local infiltration of an anesthetic following surgery. The short-acting anesthetic bupivacaine is commonly used with additional pain medication, usually opioids. Exparel®, a bupivacaine formulation that is encased in liposome to provide extended pain relief for up to three days (the usual number of days that patients require opiates for postoperative pain), has been shown to decrease the need for postoperative opioids in numerous surgeries, including immediate breast reconstruction following mastectomy.

As part of the initiative, the Breast Center is conducting a prospective study to evaluate the effectiveness of combination Exparel/Marcaine given as a field block to reduce postoperative pain in mastectomy patients and decrease the need for narcotic use. Over a year, researchers will evaluate the opiate requirements of mastectomy patients after the above quality measures are instituted. The study’s hypothesis is that patients undergoing mastectomy can have postoperative pain completely managed with local surgical site infiltration so they need only non-opioid pain relievers.

“We will learn whether infiltration of pain medications at the surgical site with longer lasting drugs such as Exparel, in combination with patient education and other multimodal therapies, can effectively and completely control postoperative pain. The ability to administer pain medicine only at the surgical site will allow a patient to have minimal pain at home and be able get back to normal activities sooner without the need for opiates,” says Dr. Valente.