ASO Author Reflections: The Time to Incorporate Opioid-Minimizing Initiatives in Your Institution is now

Past

According to recent data presented by Cogan et al.1 at the 2020 San Antonio Breast Cancer Symposium, nearly one in five opioid-naïve patients undergoing mastectomy continues to fill prescriptions for opioids well past the postoperative period. Younger women and those treated with chemotherapy are at highest risk for long-term opioid use. This postoperative vulnerability of patients undergoing surgery for cancer highlights the need to prove that opioid-sparing initiatives are feasible and do not compromise patient care. Although recent years have seen an explosion in studies demonstrating that multimodal analgesia use leads to decreased opioid-prescribing, few have found that multimodal analgesia improves pain control without opioids.

Present

The authors, building on prior work within their institution,2 set out to determine whether post-lumpectomy pain control could be improved without opioids. Their analysis demonstrated that the rate of moderate-to-severe pain decreased from 34.3% to 19.1% (p < 0.001) for lumpectomy patients who received the opioid-sparing protocol.3 The perfect combination of multimodal elements remains to be determined. A recently published retrospective study found that intraoperative nonsteroidal anti-inflammatory drugs (NSAIDs) may not be appropriate for all mastectomy patients.4 Liposomal bupivacaine is cost-prohibitive, and its superiority over traditional aqueous long-acting local anesthetics is not proven,5 as recently discussed in the American Society of Breast Surgeons’ multidisciplinary perioperative pain management guidelines.6

Future

The specific elements of the “perfect” multimodal analgesia protocol continue to evolve while novel therapies are introduced and antiquated theories are abandoned. The basic tenets will remain the same. Preoperative education and expectation-setting to minimize anxiety, pre-emptive non-opioid medications or pain-blocking interventions, intraoperative anti-inflammatory medication, and postoperative multimodal analgesia without fluid overload or restrictive diets will facilitate an expeditious return to equilibrium. Because targeted oncologic therapies are becoming the standard of care, personalized multimodal protocols specific to surgical modality, comorbidities, disease processes, risk factors, and institutional resources will be the end result. This evolution could not come at a more critical time. The American Medical Association recently reported that opioid-related mortality has increased in the wake of the Coronavirus pandemic.7 Furthermore, COVID-19 has shown us that the safest place for well patients is at home. This shared understanding coupled with multidisciplinary collaboration, the development of creative strategies for opioid minimization, and continuous assessment through quality metrics is the way forward.

Disclosure

Kristin Rojas and Patrick Borgen have received speaker's honoraria from Pacira. Claudya Morin has no conflicts of interest.