Changing the Default: A Prospective Study of Reducing Discharge Opioid Prescription after Lumpectomy and Sentinel Node B
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ORIGINAL ARTICLE – BREAST ONCOLOGY
Changing the Default: A Prospective Study of Reducing Discharge Opioid Prescription after Lumpectomy and Sentinel Node Biopsy Tracy-Ann Moo, MD1, Kate R. Pawloski, MD1, Varadan Sevilimedu, MBBS, DrPH2, Jillian Charyn, BA1, Brett A. Simon, MD, PhD3,4, Lisa M. Sclafani, MD1, George Plitas, MD1, Andrea V. Barrio, MD1, Laurie J. Kirstein, MD1, Kimberly J. Van Zee, MS, MD1, and Monica Morrow, MD1 Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; 2Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY; 3Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; 4Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY 1
ABSTRACT Background. Whether routinely prescribed opioids are necessary for pain control after discharge among lumpectomy/sentinel node biopsy (Lump/SLNB) patients is unclear. We hypothesize that Lump/SLNB patients could be discharged without opioids, with a failure rate \ 10%. This study prospectively examines outcomes after changing standard discharge prescription from an opioid/nonsteroidal anti-inflammatory drug (NSAID) to NSAID/ acetaminophen. Patients and Methods. Standard discharge pain medication orders included opioids in the first 3-month study period and were changed to NSAID/acetaminophen in the second 3-month period. Patient-reported medication consumption and pain scores were collected by post-discharge survey. Frequency of discharge with opioid, NSAID/acetaminophen failure rate, opioid use, and pain scores were examined. Results. From May to October 2019, 663 patients had Lump/SLNB: 371 in the opioid study period and 292 in the NSAID period. In the opioid period, 92% (342/371) of patients were prescribed an opioid at discharge; of 142 patients who documented opioid use on the survey, 86 (61%) used zero tablets. Among 56 (39%) patients who
Ó Society of Surgical Oncology 2020 First Received: 23 April 2020 Accepted: 9 June 2020 M. Morrow, MD e-mail: [email protected]
used opioids, the median number taken by POD 5 was 4. After the change to NSAID/acetaminophen, rates of opioid prescription decreased to 14% (41/292). The NSAID/acetaminophen failure rate was 2% (5/251). Among survey respondents, there was no significant difference in the maximum reported pain scores (POD 1–5) between the opioid period and the NSAID period (p = 0.7). Conclusions. In Lump/SLNB patients, a change to default discharge with NSAID/acetaminophen resulted in a 78% absolute reduction in opioid prescription, with a failure rate of 2% and no difference in patient-reported pain scores. Most Lump/SLNB patients can be discharged with NSAID/ acetaminophen.
In the United States, most breast cancer patients undergoing lumpectomy with sentinel lymph node biopsy (SLNB) are routinely discharged with opioids. A recent survey of 609 members of the American Society of Breast Surgeons found that approximately 8
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