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Original research
Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery
  1. Soyoun Rachel Kim1,2,
  2. Stephane Laframboise2,
  3. Gregg Nelson3,
  4. Stuart A McCluskey4,
  5. Lisa Avery5,
  6. Nastasia Kujbid2,
  7. Aysha Zia2,
  8. Marcus Q Bernardini2,
  9. Sarah Elizabeth Ferguson2,
  10. Taymaa May2,
  11. Liat Hogen2,
  12. Paulina Cybulska2 and
  13. Geneviève Bouchard-Fortier2,6
  1. 1Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
  2. 2Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
  3. 3Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
  4. 4Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
  5. 5Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
  6. 6Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Geneviève Bouchard-Fortier, Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Canada; genevieve.bouchard-fortier{at}uhn.ca

Abstract

Objectives Opioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents prescribed and pain control in patients undergoing minimally invasive surgery.

Methods A restrictive opioid prescription protocol was implemented from January through December 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for suspected malignancy were included. Simultaneously, we implemented use of multimodal analgesia, patient and provider education, pre-printed standardized prescriptions, and tracking of opioid prescriptions. Total median morphine milligram equivalents prescribed were compared between pre- and post-intervention cohorts. Patients were surveyed regarding opioid use and pain control at 30 days post-surgery.

Results A total of 101 women in the post-intervention cohort were compared with 92 consecutive pre-intervention controls. Following protocol implementation, median morphine milligram equivalents prescribed decreased from 50 (range 9–100) to 25 (range 8–75) (p<0.001). In the post-intervention cohort, 75% (76/101) used 10 median morphine milligram equivalents or less and 55 patients (54%) used 0 median morphine milligram equivalent. There was no additional increase in opioid refill requests after implementation of our strategy. Overall, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery.

Conclusions Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery, with over 50% of patients requiring no opioids postoperatively.

  • Pain
  • cancer pain
  • postoperative care

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/ijgc-2021-002968

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    Data availability statement

    Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Twitter @GreggNelsonERAS

    • Contributors SRK: Data curation, formal analysis, project administration, visualization, writing—original draft, writing—review and editing; SL: conceptualization, funding acquisition, project administration, data curation, investigation, methodology, writing—review and editing; GN: investigation, writing—review and editing; SAM: investigation, writing—review and editing; LA: statistical analysis, writing—review and editing; NK: investigation, data curation, writing—review and editing; AZ; investigation, data curation, resources, writing—review and editing; ES; resources; MB: resources, writing—review and editing; SEF: resources, writing—review and editing; TM: resources, writing—review and editing; LH: resources, writing—review and editing; PC: resources, writing—review and editing; EM: supervision; GBF: Guarantor, Conceptualization, formal analysis, funding acquisition, project administration, investigation, methodology, supervision, writing—review and editing.

    • Funding The project was supported by the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.