AUGS executive summary: Postoperative opioid prescribing after female pelvic medicine and reconstructive surgery

Abstract

Objective:

This study aimed to provide female pelvic medicine and reconstructive surgery (FPMRS) providers with evidence-based guidance on opioid prescribing following surgery. Methods: A literature search of English language publications between January 1, 2000, and March 31, 2021, was conducted. Search terms identified reports on opioid prescribing, perioperative opioid use, and postoperative pain after FPMRS procedures. Publications were screened, those meeting inclusion criteria were reviewed, and data were abstracted. Data regarding the primary objective included the oral morphine milligram equivalents of opioid prescribed and used after discharge. Information meeting criteria for the secondary objectives was collected, and qualitative data synthesis was performed to generate evidence-based practice guidelines for prescription of opioids after FPMRS procedures.

Results:

A total of 6,028 unique abstracts were identified, 452 were screened, and 198 full-text articles were assessed for eligibility. Fifteen articles informed the primary outcome, and 32 informed secondary outcomes.

Conclusions:

For opioid-naive patients undergoing pelvic reconstructive surgery, we strongly recommend surgeons to provide no more than 15 tablets of opioids (roughly 112.5 morphine milligram equivalents) on hospital discharge. In cases where patients use no or little opioids in the hospital, patients may be safely discharged without postoperative opioids. Second, patient and surgical factors that may have an impact on opioid use should be assessed before surgery. Third, enhanced recovery pathways should be used to improve perioperative care, optimize pain control, and minimize opioid use. Fourth, systemic issues that lead to opioid overprescribing should be addressed. Female pelvic medicine and reconstructive surgery surgeons must aim to balance adequate postoperative pain control with individual and societal risks associated with excess opioid prescribing.

Appropriate postoperative pain control is critical to providing high-quality surgical care, as pain control affects patient satisfaction and¹ postoperative healing² and is expected to affect health care reimbursement as models move toward value-based care.³ Opioid medications are frequently used as part of a postoperative pain control regimen; however, there are well-recognized risks associated with inappropriate opioid prescribing and use.⁴ In this complex clinical landscape, surgeons must seek to understand and balance the risks and benefits of opioid prescribing to optimize patient care. Although opioids are routinely prescribed after pelvic reconstructive surgery, there is no current consensus on best practices. Given the frequency of opioid prescribing and the inherent risks associated with opioid misuse, evidence-based guidance is needed to fill this gap. The target audience for this document is female pelvic medicine and reconstructive surgery (FPMRS) perioperative care providers. The target patient is any patient undergoing FPMRS procedures who is under consideration to be discharged home with an opioid prescription. This document uses the term opioid(s) to refer to the drugs most commonly prescribed after surgery: hydrocodone-acetaminophen, oxycodone-acetaminophen, oxycodone, codeine, hydromorphone, and morphine. When appropriate, the dose has been converted to oral morphine milligram equivalents (MME). For example, 5 tablets of 5 mg of oxycodone are equivalent to 37.5 MME, 10 tablets of 5 mg of oxycodone are equivalent to 75 MME, and 15 tablets of 5 mg of oxycodone are equivalent to 112.5 MME.

The primary purpose of this Clinical Practice Statement is to inform FPMRS perioperative care providers of best practices in postoperative opioid prescribing by summarizing published data and providing expert consensus on the strength of this literature. The secondary purpose of this Clinical Practice Statement is to identify patient- and surgical-level factors and evidence-based interventions that may have an impact on the amount of opioid required for adequate pain control. Finally, we offer suggestions for systems-level improvements that may mitigate the opioid crisis and recommendations for future research.

This document is not intended to cover all gynecologic surgical procedures; it addresses the FPMRS subspecialty. In addition, although we discuss prior opioid use in patients as a risk factor for increased postoperative opioid use, the primary framework for this document is opioid-naive patients.

FPMRS clinicians should be aware of the important role that they play in appropriate opioid prescribing while simultaneously working to support patients with appropriate postoperative pain management. At this time, available evidence indicates that effective pain management can be obtained without excessive opioid prescribing. For opioid-naive patients, we strongly recommend a prescription for no more than 15 tablets of opioids (112.5 MME) upon discharge after pelvic reconstructive surgery should be adequate for pain management. Patients who do not use opioids in the hospital can be safely discharged without an opioid prescription. In considering the evidence presented in this guidance document, it is important to emphasize that information regarding decreased opioid prescribing is presented with the firm assumption that postoperative pain should be appropriately treated. The importance of appropriate pain treatment cannot be overemphasized because poor pain management can lead to higher rates of hospitalization,⁵ increased postoperative complications,⁶ and development of chronic pain.⁷ We encourage physicians to prescribe the appropriate quantity of opioids based on patient-specific needs, rather than using uniform prescribing strategies that are not based on patient-level characteristics. Under this framework, some patients will need higher than average oral MME to achieve adequate pain control, and others will need less. Widespread adoption of ERAS protocols, increased utilization of minimally invasive surgical approaches, optimization of nonopioid analgesia, and judicious prescribing will give FPMRS clinicians the tools they need to achieve optimum pain management while minimizing risks associated with opioid overprescribing.

REFERENCES

1. Jamison RN, Ross MJ, Hoopman P, et al. Assessment of postoperative pain management: patient satisfaction and perceived helpfulness. Clin J Pain 1997;13(3):229–236.

2. Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001;87(1):62–72.

3. Centers for Medicare and Medicaid Services. Available at: https://www. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ Value-Based-Programs/Value-Based-Programs. Accessed May 10, 2021.

4. Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet 2019;393(10180):1547–1557.

5. Wagner-Johnston ND, Carson KA, Grossman SA. High outpatient pain intensity scores predict impending hospital admissions in patients with cancer. J Pain Symptom Manage 2010;39(2):180–185.

6. Apfelbaum JL, Chen C, Mehta SS, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003;97(2):534–540.

7. Brandsborg B, Dueholm M, Nikolajsen L, et al. A prospective study of risk factors for pain persisting

(Female Pelvic Med Reconstr Surg 2021;27: 643–653)

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