Background
Postoperative opioid prescription patterns play a key role in driving the opioid epidemic. A comprehensive system toward pain management in surgical patients is necessary to minimize overall opioid consumption.
Objective
This study aimed to evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring postdischarge narcotic use in morphine milligram equivalents.
Study Design
This is a prospective clinical practice study that included women undergoing inpatient pelvic reconstructive surgery from December 2018 to June 2019 with overnight stay after surgery. As a routine protocol, all the patients followed an enhanced recovery after surgery protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory surveys were collected preoperatively and on postoperative day 1. Brief pain inventory and activities assessment scale scores were collected at postoperative week 1 and postoperative weeks 4–6 after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription for controlled substances software platform, which is mandated in the state of Connecticut for all controlled substances, prescriptions, and refills. Patients were called at postoperative week 1 and postoperative weeks 4–6 to answer questions regarding their pain, the number of remaining narcotic tablets, and patient satisfaction regarding pain management. Patient electronic medical records and the Connecticut Prescription Monitoring and Reporting System were reviewed to determine whether patients received narcotic refills. Primary outcome was postdischarge narcotic use measured in morphine milligram equivalents. Secondary outcomes evaluated refill rate, brief pain inventory and activities assessment scale scores, and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range. Bivariate comparisons used Spearman’s rho (ρ) with α=0.05.
Results
A total 113 patients were enrolled; the median (interquartile range) morphine milligram equivalent prescribed (including refills) was 112.5 (112.5–112.5). The median postdischarge narcotic use was 24.0 (0–82.5) morphine milligram equivalent, which is equivalent to fewer than 4 oxycodone (5 mg) tablets. About 75% of our participants required fewer than 11 oxycodone tablets. The median unused morphine milligram equivalent was 90.0 (45–112.5). 81.4% (92/113), and 83.2% (94/113) of patients at postoperative week 1 and postoperative weeks 4–6, respectively, reported being satisfied or extremely satisfied with their postdischarge pain control. About 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the postoperative 1 and postoperative weeks 4–6 time points. At postoperative weeks 4–6, 19.5% of patients said that they filled the narcotic prescription but did not use any of the pills. The overall refill rate was 10.6% (12/113). All patients who needed a refill described the refill process as easy. In-hospital narcotic use was not predictive of postdischarge narcotic use (ρ0.065, P =.495). Patients reported median brief pain inventory scores for “average pain” of 0 (no pain) at postoperative week 1 and postoperative weeks 4–6; however, the scores did not clinically correlate with postdischarge narcotic use. Activities assessment scale scores were not correlated with postdischarge narcotic use.
Conclusion
Most patients after pelvic reconstructive surgery used fewer than 11 oxycodone (5 mg) tablets, averaging less than 4 tablets, with a third of patients not requiring any opioids. Pain and activities scores did not correlate with narcotic use. A minimal number of opioids can be prescribed because the secure electronic prescribing system allows for convenient electronic refill if required. Our practical and comprehensive pre- and postoperative protocol for pain management minimizes opioid consumption in addition to maximizing patient satisfaction.
Opioid misuse has reached epidemic proportions nationally, prompting the United States Congress to pass legislation to curb this ongoing crisis. Prescription opioid use has been identified as a key contributor to this crisis. In particular, opioids are overprescribed in postoperative patients. It is our responsibility as surgeons to identify areas within our healthcare system and surgical practice to provide appropriate pain relief after surgery and reduce the overall opioid consumption. This includes the implementation of nonopioid pain management protocols and the identification of practical strategies to curb overprescription of narcotic medications.
Why was this study conducted?
To evaluate a clinical practice model of pain management for surgical patients and to assess the utilization of electronic prescription of controlled substances to minimize postoperative opioid consumption without compromising patient satisfaction.
Key findings
On average, patients used fewer than 4 oxycodone (5 mg) tablets after pelvic reconstructive surgery. No individual patient factors were identified to predict postdischarge opioid use. High levels of patient satisfaction were found with this model of pain management.
What does this add to what is known?
Patients need limited narcotics after minimally invasive gynecologic surgery. Protocols that include enhanced recovery after surgery and electronic prescription of controlled substances further minimize opioid consumption with high levels of patient satisfaction.
Numerous initiatives have been undertaken to reduce excess opioid prescriptions across various surgical specialties. Blue Cross Blue Shield of Michigan incentivized surgeons to decrease the amount of opioids prescribed postoperatively by increasing reimbursements an additional 35% if surgeons indicated that the opioid-sparing pathway was utilized in patients undergoing general surgical procedures. Various institutions, especially in obstetrics and gynecology, have implemented creative solutions to address excess opioid prescriptions that resulted in patients achieving adequate pain control in addition to reducing postoperative opioid consumption. Several studies have found that the opioid requirement after gynecologic surgery is considerably lower than what the patients are generally prescribed. For instance, after hysterectomy, patients were prescribed a median excess of approximately 15 tablets of 5-mg oxycodone.
The practical challenge faced by providers in changing their prescription patterns is multifactorial and may relate to the concern of burdening patients by prescribing less and subsequent decrease in patient satisfaction. Therefore, the question that needs to be addressed imminently is how to implement statewide and nationwide programs that prevent overprescription and provide optimal pain relief to patients without sacrificing patient satisfaction.
We describe and evaluate a clinical practice that optimizes perioperative pain management and minimizes opioid use by successfully integrating of electronic prescription of controlled substances (EPCS). We aimed to demonstrate that our pain management protocol for patients undergoing pelvic reconstructive surgery minimizes opioid consumption in addition to providing adequate pain control and maintaining high level of patient satisfaction.
Materials and Methods
This prospective clinical practice study enrolled women undergoing inpatient pelvic reconstructive surgery. Participants were recruited at the Division of Urogynecology, Hartford Hospital, Hartford, during preoperative evaluation between December 2018 and June 2019. Hartford HealthCare Institutional Review Board approval was obtained before the initiation of the study. All adult (≥18 years of age), English-speaking women who were scheduled for inpatient pelvic reconstructive surgery were eligible to participate. Patients were excluded if they used a narcotic medication at baseline or had an active history of narcotic abuse. Patients undergoing any combined surgical procedures with another specialty were also excluded.
All participants who consented to participate completed the Brief Pain Inventory (BPI) to evaluate their baseline pain levels during their preoperative evaluation. Questions 3–6 were of specific interest to the BPI. Patients rated their pain in the last 24 hours on a scale from 0–10 (0, no pain; 10, most pain) to describe their “average,” “worst,” “least,” and “now” pain. For example, to evaluate their “now” pain, they were asked to “Please rate your pain by circling the number that best describes your pain right now.” Participants were given the same pain survey on postoperative day 1 (POD1). All surgical patients were managed using a standard enhanced recovery after surgery (ERAS) protocol that includes a specific multimodal regimen ( Table 1 ). Our group has previously found that our multimodal protocol ( Table 1 ) was effective in decreasing opioid consumption postoperatively. Patients were discharged with a dose of 15 tablets of 5-mg oxycodone or 15 tablets of 2-mg hydromorphone. We decided on 15 tablets after conducting a secondary analysis of the multimodal arm of the previously published pain management trial where we found the median narcotic requirement to be 11 tablets. In adherence with the CT state law that all narcotics be prescribed electronically using EPCS, Imprivata, a software platform for EPCS, was used to prescribe postdischarge narcotic prescriptions.
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Participants also completed the activities assessment scale (AAS) preoperatively to have baseline information regarding their level of activity. The AAS is a 13-item scale that has been validated for use after pelvic reconstructive surgery to assess postoperative function and mobility. The total score is on a scale from 0–100, where higher scores reflect better mobility. All participants were called on postoperative days 7–10 (POW1) and postoperative weeks 4–6 (POW4–6) to complete the BPI, AAS, and satisfaction surveys over the phone. Participants were also asked of the number of remaining narcotic tablets during these telephone calls. Patient electronic medical records (EMR) and the Connecticut Prescription Monitoring and Reporting System (CPMRS) were reviewed to determine whether patients received narcotic refills. Of note, CPMRS has access to prescription data from 39 states, including all neighboring states. Demographic, clinical, and surgery-related information were also obtained from EMR.
Primary outcome was postdischarge narcotic use (PDNU) measured in morphine milligram equivalents (MME), which was calculated on the basis of how many tablets were used, including the number of refill tablets. To demonstrate that adequate pain control is achieved by prescribing 15 pills only, a consensus was reached among the 4 attending surgeons in our group that a refill rate of not more than 15%, independent of surgery type, will be considered clinically acceptable and meaningful. A sample size of 89 from a population of 10,000 would afford 80% power to detect a difference of 0.09 using a 2-sided binomial test at an alpha level of 0.05. This estimate results from an assumption that the null hypothesis is 0.06 and that the alternate hypothesis is 0.15 (ie, 6% vs 15%). To have an evaluable sample of 89 patients, our target was 110 participants after accounting for 95% consent rate and 15% attrition rate. Our secondary outcomes included pain scores, activity levels, patient satisfaction, number of phone calls made to our office in the postoperative time frame, and narcotic refill rate. Descriptive statistics were used to describe baseline characteristics, types of procedures, narcotic use, and patient-centered metrics. Correlations were used to examine relationships between in-hospital narcotic use, BPI scores, AAS scores, and PDNU. Statistical analyses used SPSS 21 at α=0.05, such that P <.05 was considered statistically significant.
Results
During the study period from December 2018 to May 2019, 164 patients undergoing inpatient pelvic reconstructive surgery were screened for eligibility. Of the 131 that met the inclusion criteria, 117 were enrolled and 113 participants were included in the analysis; 4 patients were excluded because of unanticipated substantial deviations from routine pain management strategies. Baseline characteristics are presented in Table 2 . Clinical and surgical factors are presented in Table 3 , whereas the breakdown of reconstructive procedures is presented in Table 4 . More than half of the patients (54.7%) underwent hysterectomy with vaginal approach being the most predominant mode of surgery for prolapse repair.
