Reducing post-op opioid use with pre-op oral analgesics

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Presenting at the 2019 American Association of Gynecologic Laparoscopists (AAGL) Global Congress in Vancouver, British Columbia, Katherine A. Smith, MD, described how advanced administration of preoperative oral analgesics could reduce patient use of opioids immediately after minimally invasive hysterectomy for benign disease. 

Methods
The randomized controlled trial included women undergoing the procedure between January 2018 to October 2018. Sixty women aged 35-67 years participated and were randomized to treatment (n = 30) and control (n = 30). Patients assigned to the treatment arm self-administered oral celecoxib, gabapentin, and acetaminophen 3-4 hours prior to surgery. Patients in the control arm received the same medications in the pre-anesthesia care unit (PACU) approximately 1 hour before surgery. In addition to these medications, all women received nausea and vomiting prophylaxis intravenously. The authors collected the times of oral medication ingestion and orogastric tube placement. 

Patients were administered intravenous ketorolac postoperatively and pain scores were assessed on an 11-point numeric rating scale at 30 and 60 minutes after surgery, and at the time of PACU discharge. Pain medications and antiemetics were administered as needed prior to discharge. Opioid consumption data were collected and converted to oral morphine equivalent (OME). On postoperative Day 10, patients were sent an e-mail survey assessing patient satisfaction of the medication regiment on a five-point Likert scale and surgical recovery score, which was a 13-point survey aimed at assessing the patient’s surgical recovery. 

Findings
Fifty-three subjects (29 treatment and 24 control) were included in the final study results. Baseline characteristics, including age, body mass index, and tobacco use, were similar between the treatment and control arms. However, preexisting gastro-esophageal reflux was higher in the treatment arm (20.7% vs. 0.0%, P = .026). The authors found that 24.1% of women in the treatment arm required OME > 50 compared to 41.7% of the control group (P = .174). There were no significant differences in pain score at discharge (P= .234), patient satisfaction (P = .90) or surgical score (P = .189). 

Conclusion
The authors believe that their findings indicate that advanced administration of preoperative oral analgesia trended towards a decrease in immediate postoperative opioid use when compared to immediate preoperative administration. “Because our overall narcotic use for outpatient hysterectomy was generally very low, a larger sample would definitely allow us to have a more precise detection in any differences between narcotic requirement in the two groups,” said Dr. Smith.