Reducing Narcotics for Postoperative Pain in Breast Surgery Patients

The opioid use epidemic has spurred a reconsideration of the use of narcotic pain medications for many indications, including postoperative pain management. Recent studies have shown that narcotics prescribed for postoperative pain control may be overprescribed, resulting in excess unused pills that could lead to potential abuse.

“For years, I don’t think many surgeons realized the magnitude of the amount of narcotic pain medications that they prescribed to patients for postoperative or other pain management. We were surprised and disheartened to see that the prescriptions we were writing to help with postoperative pain were unknowingly contributing to dependency and abuse in America,” says Stephanie Valente, DO, a surgeon with the Department of Breast Services at Cleveland Clinic.

Clear prescribing standards regarding the number or type of narcotics for adequate postoperative pain control are sometimes lacking, including for breast surgery. To address this situation, Cleveland Clinic Department of Breast Services studied its opioid prescribing practices and conducted a prospective study with a goal of providing optimum pain control without excess narcotic medications. “As a group of surgeons at a large academic institution, we wanted to see how we could standardize and improve our narcotic prescribing patterns while engaging patients in the quality improvement process,” says Dr. Valente.

Looking at past practices

Breast Services researchers reviewed prescribing data on breast surgery patients treated in 2017 to establish baseline postoperative narcotic prescribing patterns. Based on data from 100 consecutive patients, inconsistencies were found in the type and number of narcotics prescribed: Tramadol, Tylenol-3, Norco/hydrocodone and Percocet®/oxycodone prescriptions ranged from zero to 40 pills.

The median number of pills varied with procedures: 15 for excisional biopsy/lumpectomy, 20 for mastectomy and 28 for mastectomy with reconstruction. This information was used to educate surgeons before implementing any changes.

A prospective analysis

The number of pills prescribed was reduced to 10 for excisional biopsy/lumpectomy and to 25 for mastectomy with reconstruction, with no reduction in the 20 pills prescribed for mastectomy. A group of 100 patients was followed to find out how many pills they actually used.

The median number of pills taken by patients was significantly less than what was prescribed for all procedures: one pill for excisional biopsy/lumpectomy, three for mastectomy and 18 for mastectomy with reconstruction. Nearly half (40 percent) of the patients reported using zero narcotics following their procedure. “When we decided on the number of narcotics to prescribe, we were concerned that it might be too little. We were surprised how little narcotics patients took and how many patients took no narcotics at all. Many patients opt for ice and Tylenol,” says Dr. Valente.

Future plans

Guided by this data, Breast Services clinicians are focusing on surgeon and patient education. “Pain medications can have a necessary, temporary role in the management of surgical pain. Patients need to understand that there will be some degree of discomfort from surgery and know that the amount of narcotics given after surgery will not be renewed. At the same time, we now have a better understanding of multi-modality non-narcotic alternatives for pain management. Many breast surgery patients will be able to safely avoid all postoperative narcotics,” says Dr. Valente.

The study was presented at the 2019 annual meeting of the American Society of Breast Surgeons.