ASO Author Reflections: Discharge Without Opioids After Lumpectomy with Sentinel Node Biopsy Should Be the Norm, Not the Exception

Past:

The opioid crisis has led to efforts to curb opioid over-prescription in the postoperative setting. Institutional and society guidelines on the number of opioid tablets that should be prescribed after various procedures have been developed,^1,2 with 0–10 tablets recommended for lumpectomy with sentinel node biopsy (SLNB). Although some surgeons have stopped prescribing opioids after lumpectomy, a recent survey by the American Society of Breast Surgeons (ASBrS) showed that 80% still routinely prescribe opioids.² These figures indicate that despite an increased awareness of the adverse effects of prescription opioids, there are still barriers to adopting non-opioid discharge protocols. This may be due to the paucity of literature demonstrating feasibility and outcomes of discharge without opioids after lumpectomy/SLNB. There is also concern that a switch to discharge without opioids could result in poorly controlled postoperative pain leading to subsequent patient calls and opioid prescription after discharge. Our study was designed to examine these concerns.³

Present:

At Memorial Sloan Kettering Cancer Center, we eliminated routine opioid prescriptions after lumpectomy/SLNB and, instead, began the practice of discharging patients with non-steroidal anti-inflammatory drug (NSAID)/acetaminophen.³ Patients with NSAID contraindications continued to receive opioids. Our standard enhanced recovery after surgery protocol, which includes intraoperative ketorolac and acetaminophen, and injection of local anesthetic at the surgical site, was unchanged. We prospectively examined outcomes before and after the change in discharge medication. The frequency of opioid prescription decreased from 92% to 14% after implementing discharge with NSAID/acetaminophen: a 78% absolute reduction in opioid prescription rate. The NSAID/acetaminophen failure rate was low; only 2% of patients discharged on this regimen were subsequently prescribed an opioid. During postoperative days (PODs) 1–5, most patients reported no pain or mild pain (approximately 60%) irrespective of discharge medication, and there was no difference in the maximum reported pain scores among patients discharged with opioid versus NSAID/acetaminophen (p=0.7). At our center, discharge without opioids after lumpectomy/SLNB is now the norm, with exceptions made only for patients with NSAID contraindications.

Future:

There are numerous studies documenting opioid over-prescription across multiple surgical specialties.^4,5 While there has been a push toward reducing the number of opioid tablets that are prescribed after surgery, there are procedures in which patients do not require opioids for postoperative pain control. Our study demonstrates that routine discharge without opioids can be accomplished with a low failure rate for lumpectomy with SLNB. Similar non-opioid pain management strategies, including non-narcotic analgesics, local anesthesia and regional nerve blocks, should be studied for a variety of procedures. Approximately 14% of our patients continue to receive opioid prescriptions at discharge, due to medical contraindications to NSAIDs. Investigation into whether these patients could be discharged with alternatives to NSAIDs is also warranted.