Abstract P1-20-23: Eliminating postoperative opioids for outpatient breast surgery in a large integrated healthcare system
Authors: Patel Avani R , Kuehner Gillian E , Chang Sharon B. 
Published: March 2020

Introduction: The epidemic of opioid addiction and overdose has become a public health emergency in the United States. Opioids prescribed for postoperative pain management have contributed significantly to this epidemic. At the Permanente Medical Group (TPMG), reducing postoperative opioid prescriptions has become a priority. A pilot study in 2016 led by TPMG breast surgeons showed that pain after lumpectomy can be managed effectively without opioids. The results of this study were disseminated to all TPMG breast surgeons via a February 2017 webinar. In November 2018, TPMG implemented an outpatient Enhanced Recovery After Surgery (ERAS) initiative that included reducing postoperative opioid prescriptions. The objective of our study was to evaluate self-reported changes in TPMG breast surgeon opioid-prescribing practices after these interventions.

Methods: An online survey was created to assess perioperative and postoperative practices. This survey was distributed to TPMG breast surgeons before the 2017 educational webinar about non-opioid regimens, and again in June 2019, more than 6 months after the implementation of the outpatient ERAS initiative. Questions included how surgeons manage patient expectations during the initial consultation, surgeons’ preoperative pain medication regimens, intraoperative pain management including nerve blocks, local anesthetics, ketorolac use, and postoperative pain management. We used a chi-square test to compare differences between the two surveys.

Results: We received 13 responses from a group of over 100 TPMG breast surgeons in 2017 and 29 responses from 59 surgeons in 2019. Overall, self-reported non-opioid regimens increased between 2017 and 2019, with only 23% of surgeons using these regimens for lumpectomy in 2017 and 79% in 2019 (p&lt;0.001).

TPMG Self-Reported Opioid Prescribing Patterns After Lumpectomy, 2017 vs 2019# Opioid Tablets Prescribed After Lumpectomy% of Surgeons Prescribingp-value2017201902379&lt;0.0011 to 10870.9311 to 201570.3921 to 302330.045&gt;30150NAUnspecified153NA

Notably, non-opioid regimens were also reported by 66% of surgeons for lumpectomy with sentinel lymph node biopsy (SLNbx), 41% for mastectomy without reconstruction, and 14% for mastectomy with implant-based reconstruction.

2019 Self-Reported Opioid Prescribing Patterns After Different Types of Breast Operations% of Surgeons Prescribing# Opioid Tablets Prescribed, by Type of OperationLumpectomyLumpectomy With Sentinel Lymph Node BiopsyMastectomy Without ReconstructionMastectomy With Reconstruction0796641141 to 1071021311 to 20717282821-3033710&gt;310007Unspecified3333Per plastics00034

Conclusion: Self-reported postoperative opioid prescribing practices for breast surgery have changed significantly after implementation of TPMG initiatives, with the majority of TPMG breast surgeons prescribing no opioids after lumpectomy with or without SLNbx, and many prescribing no opioids after mastectomy. In future work, we aim to validate the self-reported data using pharmacy prescription data from 2017-2019. We also plan to identify perioperative factors that are predictive of successful non-opioid postoperative pain management such as the use of nerve blocks, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, and acetaminophen.

Citation Format: Avani R Patel, Gillian E Kuehner, Sharon B. Chang. Eliminating postoperative opioids for outpatient breast surgery in a large integrated healthcare system [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-23.