Older Women and Opioid Analgesia after Breast Cancer Surgery

Older Women and Opioid Analgesia after Breast Cancer Surgery.

Many women with breast cancer will undergo surgery at least once during the course of their treatment, as surgery is the definitive treatment for malignancies of the breast (Warburton et al., 2018). Up to 60% of patients endure persistent pain following breast cancer surgery, resulting in reduced overall quality of life and impaired function (Wang et al., 2018). Breast cancer surgery patients are at risk for complications that predispose them to persistent postoperative pain, including uncontrolled postsurgical pain; fluid collections in the wound with subsequent drain placement; and development of fistulae and/or adhesions (Feeney, Tormey, & Harmon, 2018).

Among women diagnosed with breast cancer, over 50% are older than 60 (Varghese & Wong, 2018); therefore, a greater number of older women will undergo surgical intervention for breast cancer than their younger counterparts. As age increases, the risk of having other comorbidities as well as surgical risk itself increases, potentially leading to more complications (Wasif, Neville, Gray, Cronin, & Pockaj, 2019). Of note, older women may be at risk for carrying a higher postoperative pain burden that necessitates treatment with opioid analgesia, which includes both synthetic analgesics and those derived from opium. In their study of postoperative pain in older women following breast surgery, Kudach, Dunwoody, and Wesmiller (2018) found that women age 60 and older reported higher pain scores (an average of 4.47 out of 10) than their younger counterparts ranging in age between 37 and 59 (3.77 out of 10). Pagán (2018) reported that women of all ages generally report pain more frequently with higher pain scores and endure pain longer than men. In a study of cancer-related pain, Fairchild (2010) found that patients over 65 years of age suffer from more uncontrolled pain, and women report significantly higher pain intensity; lower satisfaction with pain control; lower adherence to prescribed analgesics; and a higher tendency to stop medications when they are feeling better. Older adults are hesitant to discuss escalations of their pain (Kahana et al., 2009; Makris et al., 2015), not realizing its undertreatment results in chronic pain and impairs functionality and quality of life (Bouri et al., 2018; Ruben, Meterko, & Bokhour, 2018). As older adults progressively age, degenerative processes such as osteoarthritis, spinal degeneration, declining immune competence (causing neuropathic pain and post-herpetic neuralgia), and a higher prevalence of cancer predispose them to suffer from uncontrolled pain—this insufficiently treated pain interferes with everyday physical, cognitive, and social competence, thus limiting quality of life (Eiche & Schache, 2016). Eiche and Schache elucidate that, although pain prevalence is higher with older than with younger adults, older adults receive significantly less analgesia for varied reasons including clinicians’ uncertainties regarding treatment of pain and complications in eliciting pain information, particularly from cognitively affected patients.

While collecting data for the parent study, we noted that older participants often elected not to take opioids following surgery, even though they were prescribed. In this secondary analysis, we sought to explore postoperative pain experiences in older women after breast cancer surgery. We questioned whether the reasons women avoided postoperative opioid analgesia included fear of addiction, stigma, and/or its adverse effects, including nausea, constipation, and somnolence.

A component of the parent study examines the variability of postoperative nausea and vomiting and co-occurring symptoms, including pain, in women age 18 to 90 undergoing surgery for early stage breast cancer. For this project, we focused on a subsample of women who are age 65 or older. The purpose of this study was to explore the factors that influenced the amount of opioid analgesia older study participants utilized during the 48-hour period following hospital discharge after breast cancer surgery.

Methods

Design

The present study was a secondary analysis of data from an ongoing study approved by the Institutional Review Board at the University of Pittsburgh. We employed a cross-sectional cohort study design (Hudson, Pope, & Glynn, 2005). All study participants from the parent study who were age 65 and older were included in this cohort of women with early-stage breast cancer. We then retrospectively assessed the outcome of each study participant’s pain experience and employed these data to discover the characteristics of older women with breast cancer who required opioid analgesia following discharge from the post-anesthesia care unit (PACU) and those who did not require opioid analgesia during this time period.

Setting

A member of the research team recruited and consented participants and collected baseline data in the preoperative holding area of a large teaching hospital specializing in the care of women, which houses a nationally-known comprehensive Breast Care Program. Data were also collected at a community hospital affiliate where the same group of surgeons practice. Prior to recruiting and consenting patients to the parent study, research associates received extensive instruction on participant recruitment and data collection procedures specific to the study. Following surgery, research associates collected information regarding pain, nausea, vomiting, and medications administered during the PACU stay. Data pertaining to the 48-hour postoperative period were collected via follow up telephone calls to each study participant by research associates using surveys designed specifically for the parent study.

Sample

Inclusion criteria for the parent study required the diagnosis of early-stage breast cancer, classified as Stage I, II, or IIIa per the American Joint Committee on Cancer staging criteria (Edge et al., 2010); no clinical evidence of distant metastases; and scheduled to undergo breast surgery lasting four hours or less. Exclusion criteria included a previous history of neurologic conditions such as stroke, head injury, spinal cord injury, intracerebral hemorrhage, and surgical procedures anticipated to last greater than four hours. For this secondary analysis, only data from study participants age 65 or older were used.

Variables and Procedures to Collect Data

Age, Race, and Ethnicity

Demographic data were collected by the research team in the pre-operative holding area. Study participants self-reported age, smoking status, and history of postoperative nausea and vomiting. In addition, they reported race/ethnicity as either Caucasian/White; African American/Black; Hispanic/Latino; Native American/Alaskan Native; Hawaiian/Other Pacific Islander; or Asian. For this secondary analysis, none of the study participants identifying as Hispanic/Latino, Native American/Alaskan Native, Hawaiian/Other Pacific Islander, or Asian met inclusion criteria for age.

Surgical Procedures

Data regarding the specific surgical procedure performed were collected via chart review by a research team member. Surgical procedures included unilateral or bilateral total mastectomies in addition to unilateral or bilateral segmental, also called partial, mastectomies, and re-excisions due to inadequate margins from the first procedure. During their initial breast surgeries, most study participants also undergo sentinel node biopsies to assess for the presence of nodal metastases. Subsequent axillary lymph node dissection is indicated, if lymph nodes are positive; however, due to significant progress in the surgical management of breast cancer, complete dissection is not often required in the low-risk population of patients with early-stage invasive breast cancer (Black & Mittendorf, 2013).

Preoperative Medications

A member of the research team recorded the names and dosages of preoperative medications administered to each participant, if any.

Intraoperative Anesthetic

Research team members reviewed participants’ charts to determine the intraoperative medications each received. Anesthetics included desflurane; nitrous oxide; sevoflurane; sevoflurane with nitrous oxide; and, occasionally, Total Intravenous Anesthesia (TIVA).

Mean Postoperative Pain Scores

Research associates recorded the time of admission and discharge for each participant during her PACU stay. The average length of PACU stay for 55 of the 57 older women included in this secondary analysis for whom PACU admission and discharge times were complete was three hours and 34 minutes. Postoperative pain scores were assessed by the PACU nurse every 15 minutes while the study participant recovered in the PACU and each score recorded by a research team member. The PACU nurse asked each participant to rate her pain according to the 11-point (0–10) Numerical Rating Scale (NRS). Data from the literature portrays the NRS as a valid, reliable scale with excellent reproducibility in scoring exacerbations of pain reflected by a Cohen’s Kappa value of K=0.80 with a 95% confidence interval between 0.61 and 0.91 (Brunelli et al., 2010). The research team member then recorded the participant’s responses each time the nurse asked about pain level. Each study participant’s average pain score (the sum of all recorded pain scores divided by the number of pain level queries) was included in the analysis.

Cumulative Dose of PACU Opioids

The cumulative dose of postoperative opioid analgesia each woman received is reported in morphine milligram equivalents (MMEs). A research assistant recorded each dose of pain medication administered and converted it to MMEs (“MME for Commonly Prescribed Opioids,” 2019) per guidelines created by the Centers for Disease Control and Prevention (CDC).

PACU Opioid Type

A member of the research team recorded the name and dosage of opioid pain medication each participant received while in the PACU as the attending nurse administered the medication. Opioids received in the PACU include Dilaudid® (hydromorphone); OxyIR® (oxycodone 5 mg); and Sublimaze® (fentanyl).

48-Hour Pain Scores

Members of the research team collected 48-hour pain scores as part of the post-discharge nausea and vomiting (PDNV) Survey via telephone two days following discharge from the PACU after breast surgery. Study participants reported pain according to the 11-point NRS.

48-Hour Opioid Drug Type

The types of opioid analgesia each woman self-administered is included in the PDNV Survey. These medications include OxyIR® (oxycodone 5 mg); Norco® (hydrocodone bitartrate 5 mg combined with acetaminophen 325 mg); Vicodin® (hydrocodone bitartrate 5 mg combined with acetaminophen 300 mg); Percocet® (oxycodone 5 mg combined with acetaminophen 325 mg); and Ultram® (tramadol hydrochloride 50 mg).

Number of Opioid Tablets Taken at 48 Hours

The number of tablets taken from the supply of opioid analgesia prescribed for each participant 48 hours following discharge is also included in the PDNV Survey. Each participant reported the number of tablets self-administered in the 48-hour period following discharge. If a study participant indicated that she chose not to employ opioid analgesia during this 48-hour period, the researcher asked the reason for her decision.

MME of Opioid Tablets Taken at 48 Hours

This variable is the result of the conversion of Number of Opioid Tablets Taken at 48 Hours into MMEs for each participant who required opioid analgesia.

Analysis

We employed a regression modeling approach to discover the factors that influence the amount of opioid analgesia older women with breast cancer utilize for pain management in the 48 hours following discharge. This is quantified by the outcome variable MME of Opioid Tablets Taken at 48 Hours. Using SPSS 25 (IBM SPSS Inc., Chicago, IL), we performed linear regression using forward selection to determine which, if any, of the explanatory variables predicted the dosage of opioid analgesia this cohort reportedly self-administered during this time period.

Results

Sample Characteristics

Data describing the 57 women included in the current analysis are summarized in Table 1. These characteristics include age; ethnicity; surgery type; preoperative medications; intraoperative anesthetic; mean postoperative pain scores; type of opioid received while in the PACU; cumulative dose of opioids received in the PACU; pain scores 48 hours post-discharge; opioid drug types taken 48 hours post-discharge; and total number and dosages of prescribed opioid tablets taken 48 hours post-discharge.

Table 1.

Summary of characteristics of both groups of study participants

Variable	Self-administered Opioids from Time of Discharge through 48 Hours after Discharge (N=28)	No Opioid Use from Time of Discharge through 48 Hours after Discharge (N=29)
Age (years)	Mean = 71.36 ± 5.47	Mean = 72.41 ± 4.82
	95% CI (69.2 – 73.48)	95% CI (70.58 – 74.25)
65–70	15 (53.6%)	10 (34.5%)
71–74	7 (25%)	11 (38%)
75–80	3 (11%)	6 (21%)
81 or older	3 (11%)	2 (7%)
Race and ethnicity
Black/African American	2 (7%)	2 (7%)
White/Caucasian	26 (93%)	27 (93%)
Surgical types
Unilateral segmental mastectomy	20 (71%)	20 (70%)
Bilateral segmental mastectomy	1 (3%)	1 (3%)
Unilateral total mastectomy	6 (21%)	4 (14%)
Bilateral total mastectomy	1 (3%)	4 (14%)
Preoperative medications
None	15 (53.6%)	16 (55.2%)
Fosaprepitant (Emend®) only	1 (3%)	4 (13.8%)
Fosaprepitant + acetaminophen	4 (14.2%)	2 (7%)
Fosaprepitant + scopolamine	2 (7%)	2 (7%)
Acetaminophen (Tylenol®) only	4 (14.2%)	3 (10%)
Acetaminophen + celecoxib (Celebrex®)	0	2 (7%)
Acetaminophen + perphenazine (Trilafon®) + Gabapentin (Neurontin®)	1 (3%)	0
Acetaminophen + perphenazine + gabapentin + celecoxib	1 (3%)	0
Intraoperative anesthesia
Sevoflurane	19 (69%)	15 (52%)
Desflurane	1 (3%)	0
Nitrous oxide	2 (7%)	1 (3%)
Nitrous oxide + sevoflurane	4 (14%)	4 (14%)
Total IV anesthesia (TIVA)	2 (7%)	9 (31%)
Mean postoperative pain scores	Mean = 3.71 ± 2.24	Mean = 2.27 ± 2.22
	95% CI (2.84 – 4.58)	95% CI (1.43 – 3.12)
0	5 (18%)	11 (38%)
1 – 1.9	0	3 (10%)
2 – 2.9	3 (11%)	3 (10%)
3 – 3.9	6 (21%)	4 (14%)
4 – 4.9	3 (11%)	3 (10%)
5 – 5.9	7 (25%)	3(10%)
6 – 6.9	2 (7%)	2 (7%)
7 – 7.5	2 (7%)	0
PACU opioid type
None	7 (25%)	17 (59%)
Hydromorphone (Dilaudid®)	11 (39%)	8 (28%)
Hydromorphone + fentanyl (Sublimaze®)	0	1 (3%)
Hydromorphone + oxycodone (OxyIR®)	2 (7%)	1 (3%)
Oxycodone (5 mg oral)	1 (3%)	0
Fentanyl	7 (25%)	1 (3%)
Cumulative dose of PACU opioids [in Morphine Milligram Equivalents (MMEs)]	Mean = 2.46 ± 2.62	Mean = 1.60 ± 2.68
	95% CI (1.44 – 3.47)	95% CI (0.58 – 2.62)
0	7 (25%)	17 (59%)
0.1 – 0.9	5 (18%)	1 (3%)
1 – 1.9	2 (7%)	2 (7%)
2 – 2.9	6 (21%)	2 (7%)
3 – 3.9	1 (3%)	0
4 – 4.9	1 (3%)	1 (3%)
5 – 5.9	2 (7%)	2 (7%)
6 – 6.9	3 (11%)	1 (3%)
7 – 7.9	0	1 (3%)
8 – 8.9	0	0
9 – 9.2	1(4%)	1 (3%)
48-hour pain scores	Mean = 4.21 ± 2.54	Mean = 1.9 ± 1.88
	95% CI (3.23 – 5.20)	95% CI (1.18 – 2.61)
0	0	8 (28%)
1 – 2	10 (36%)	11 (38%)
3 – 4	6 (21%)	9 (31%)
5 – 6	7 (25%)	0
7 – 8	3 (11%)	1 (3%)
9 – 10	2 (7%)	0
48-hour opioid drug type		0
Hydrocodone bitartrate + acetaminophen 325 mg (Norco®)	14 (50%)
Hydrocodone bitartrate + acetaminophen 300 mg (Vicodin®)	1 (3%)
Oxycodone (OxyIR®) 5 mg	5 (18%)
Tramadol hydrochloride (Ultram®) 50 mg	6 (21%)
Oxycodone 5 mg + acetaminophen 325 mg (Percocet®)	2 (7.1%)
# of opioid tablets taken at 48 hours	Mean = 9.52 ± 15.46	0
	95% CI (5.42 – 13.62)
1 – 2	15 (52%)
3 – 4	4 (14%)
5 – 6	3 (11%)
7 – 8	2 (7%)
9 – 10	4 (14%)
MME of opioid tablets taken at 48 hours	Mean = 9.52 ± 15.46	0
	95% CI (5.42 – 13.62)
5 mg	10 (35.7%)
7.5 mg	2 (7.1%)
10 mg	2 (7.1%)
15 mg	3 (10.7%)
20 mg	2 (7.1%)
25 mg	2 (7.1%)
30 mg	1 (3.6%)
40 mg	1 (3.6%)
50 mg	4 (14.3%)
52.5 mg	1 (3.6%)

Demographic Characteristics

The average participant was 71.89 years old, with age 72 being the most common age in this cohort of older women, representing 17.5% of the sample. The majority of the sample was White/Caucasian (91.2%)—four participants (7%) were Black/African American. No other ethnicities were included in the analysis.

Surgical Characteristics

At 64.9% (n=30), the majority of women included in this study did not receive any preoperative medications. Of the 26 women who were premedicated, seven (27%) received acetaminophen (Tylenol®) by mouth, and seven (27%) received acetaminophen in combination with other medications. A unilateral segmental mastectomy was the most commonly performed surgical procedure on this cohort of women, with 64.9% (n=26) undergoing either a right or left-sided segmental mastectomy. The most commonly administered anesthetic agent for this cohort was sevoflurane (n=34, or 59.6% of participants).

PACU Characteristics

The mean combined pain scores while in the PACU was 2.98 out of a possible “10” with “0” being the most commonly reported average score (26.3%). Average pain scores ranged from zero to 7.5 on the NRS. The number of women who did not receive any opioid analgesia while in the PACU totaled 24 out of 57 (42.1%). Of patients receiving analgesics, the average cumulative morphine equivalent received was 2.02 mg. Dilaudid® (hydromorphone) was the most frequently administered agent, with 19 of the 25 women who required opioid analgesia during their PACU stay (76%) receiving at least one dose of hydromorphone. A total of eight participants (14%) received Sublimaze® (fentanyl) either as a single agent or in combination with another opioid.

48-Hour Post-Discharge Characteristics

The mean post-discharge pain score among this cohort of older women was 3.04 with “2” being the most commonly reported (19.3%). At this timepoint, eight study participants (14%) reported no pain, and 29 (51%) required no opioid analgesia post-discharge. Table 2 lists responses study participants provided as rationale for not requiring opioid analgesia.

Table 2.

Verbal responses for not taking prescribed opioid analgesia after discharge

Reason Given for Not Taking Prescribed Opioid Analgesia after Discharge	Age
“Vicodin n’at upsets my stomach—ice packs controlled my pain well enough.”	72
“No, I did not fill the prescription. My pain was never bad enough that I thought it was necessary.”	71
“I never needed any pain medication and did not take any Tylenol. I feel very fortunate. It may be hard to believe, but I did not experience any pain following surgery.”	65
“I did not take (it) because I had it before, and it made me nauseated. My pain was adequately controlled with over-the-counter meds.”	67
“I didn’t need any pain medicine—I didn’t even bother to fill the prescription. Surgery was a breeze.”	72
“I got a written prescription, but they never brought me an actual bottle of tablets. I ended up not needing it filled because it was not needed. My pain was relieved by ibuprofen.”	68
“I did fine with ibuprofen at home but had horrible pain in recovery room. Two doses of IV Toradol didn’t touch it—they had to control it with morphine. I took ibuprofen that night, maybe the next day--I took my prescription home, but I didn’t need it.”	69
“I did not fill the prescription. I had a history of using pain medication to help with a broken rib, and it took longer than I expected to get off the tablets. I also slept in a recliner for part of the night for about a month. This time, I used Extra Strength Tylenol for pain instead.”	68
“I took my script home but didn’t fill it. I have a high pain tolerance. Tylenol took care of my pain. I guess I’m paranoid. I don’t take anything since I had codeine for my cough when I was in college 50 years ago and didn’t like the way it made me feel. After that, I would go to parties and make sure I covered my drinks. After that, I wouldn’t even take aspirin! I took extra strength Tylenol, no more than 2000 mg/day and used heating pads. Prayers help me feel better.”	71
“Breast surgery is really not that painful—I can’t remember if they brought me my tablets to take home or not, but I didn’t need it. My appendectomy was more painful that any of my three breast surgeries.”	72
“I got my prescriptions for Norco filled but did not take them because I really didn’t experience pain at the time of my surgeries. I keep them around to take when I really want them but try to avoid them because they are not good for my constipation.”	76
“I took Tylenol one time. I filled my prescription, but I just never needed it.”	77
“I never filled my prescription because I really had very minimal pain and only the day after my surgery. Since I had a son in law who died of a drug overdose, I am extremely reluctant to use prescription pain drugs of any sort. Also, since I had both a knee and hip replacement, and both were very much more painful than my breast surgery, my pain would have to have been MUCH more extreme to even consider a prescription pain med. My breast pain never reached the level at which I would have requested a prescription drug. I may have taken Arthritis Strength Tylenol 1–2 times for my breast pain. Ordinarily, since I still have moderate pain due to arthritis in my knees and hips, I usually have taken Tylenol for the day before any breast pain would develop.”	69
“I didn’t need it, so they didn’t prescribe any for me. My first day, I took Tylenol because I was sore. I used ice after my biopsies and was told to avoid heat.”	74
“I didn’t take any pain medicine because I never needed it. I didn’t take the prescription offered to me because I didn’t have any pain.”	70
“I filled a prescription for 10 Lortab-5s, but I did not use them. I’m not a pill popper! I got it filled just in case. My pain was relieved by Tylenol.”	69
“I did not fill the prescription because I did not need it. I only had minimal pain, mostly discomfort.”	72
“I got my prescription filled but didn’t take it. My pain is mostly related to my knees, for which I use CBD oil. I am taking Tylenol 1000 mg every 6 hours around the clock to keep this pain manageable.”	72

Of those who employed opioid pain relief (49%, n=28), nearly half self-administered only one tablet of their prescribed opioids. As illustrated in Table 1, the remaining 16 of 28 women self-administered between two and 10 opioid tablets each. Norco® (hydrocodone bitartrate 5 mg combined with acetaminophen 325 mg) was most frequently prescribed, and 14 of the 28 women requiring prescription opioids reported taking Norco®. Of these 28 study participants requiring opioid analgesia, six self-administered Ultram® (tramadol) following surgery; however, nearly half of these women also employed tramadol for the relief of pain caused by chronic conditions such as osteoarthritis prior to breast surgery and continued to do so postoperatively. Figure 1 categorizes the opioid dosages self-administered during the 48-hour post-discharge period and the percentages of these 28 women in each dosage category.

Figure 1.

Opioid dosages and the percentages of participants taking each during the 48-hour post-discharge period following breast cancer surgery.

Associations among Factors for Opioid Use within 48 Hours Post-Discharge

Regression modeling revealed, at α=0.05, that 48-Hour Opioid Drug Type (B=0.900, SE=0.220, p<0.001, semi-partial r²=0.219) and PACU Opioid Type (B=0.508, SE=0.215, p=0.022, semi-partial r²=0.073 ) significantly predicted MME of Opioid Tablets Taken at 48 Hours. None of the other variables employed in this secondary analysis were significant predictors of the amount of opioid analgesia study participants required to control their postoperative pain during the 48-hour period after discharge. Table 3 represents correlations among the continuous variables employed in this analysis.

Table 3.

Correlations among continuous variables included in the analysis

		Age	Mean Postoperative Pain Scores	Cumulative Dose of Post-Anesthesia Care Unit (PACU) Opioids***	48-Hour Pain Scores	Cumulative Dose of Opioid Tablets Taken at 48 Hours***
Age	Pearson Correlation	1	−0.177	−0.134	−0.156	−0.010
	Sig. (2-tailed)	--	0.188	0.319	0.248	0.943
Mean Postoperative Pain Scores	Pearson Correlation	−0.177	1	.724**	.368**	.349**
	Sig. (2-tailed)	0.188	--	<0.001	0.005	0.008
Cumulative Dose of Post-Anesthesia Care Unit (PACU) Opioids***	Pearson Correlation	−0.134	.724**	1	.339**	.280*
	Sig. (2-tailed)	0.319	<0.001	--	0.010	0.035
48-Hour Pain Score	Pearson Correlation	−0.156	.368**	.339**	1	.418**
	Sig. (2-tailed)	0.248	0.005	0.010	--	0.001
Cumulative Dose of Opioid Tablets Taken at 48 Hours***	Pearson Correlation	−0.010	.349**	.280*	.418**	1
	Sig. (2-tailed)	0.943	0.008	0.035	0.001	--

^***.Units given in Morphine Milligram Equivalents (MMEs).

^**.Correlation is significant at the 0.01 level (2-tailed).

^*.Correlation is significant at the 0.05 level (2-tailed).

Discussion

The main finding of this study was that the majority of older women in this cohort (29 out of 57, or 51%) did not experience pain severe enough to warrant high dosages of opioid analgesia following their respective early-stage breast cancer surgeries. This is reflected in the low overall mean PACU pain scores in this cohort of only 2.98 out of 10; the average dosage of opioid analgesia received in the PACU of only 2.02 MMEs; and the mean dosage of 9.52 MMEs taken 48 hours after discharge from PACU. Because the quality and quantity of postoperative breast surgery pain is dependent upon the procedure performed (Murphy et al., 2019), the low overall pain scores and amount of morphine equivalents required may be attributed to the high number of women in this sample who underwent segmental mastectomies (n=41), which are considered less invasive than total mastectomies. The two factors our analysis revealed as having significant effects on the amount of opioid analgesia required were PACU Opioid Type and 48-Hour Opioid Drug Type. This finding may indicate that the type of opioid analgesia administered both in PACU and while recovering at home predicts the amount of analgesia required by patients recovering from breast cancer surgery following discharge from the hospital. However, more extensive research comparing patients’ responses to different combinations of analgesia is needed to confirm this finding.

Table 2 lists verbal responses given by some of these older study participants when asked to explain their reasons for choosing not to fill their opioid pain medication prescription post-discharge. While responses varied, two of these study participants mentioned that they followed the post-discharge instruction to apply ice to the surgical wound, and this decreased their pain sufficiently. Another 11 of the respondents mentioned managing their postoperative pain with over-the-counter preparations, such as acetaminophen (Tylenol®) and ibuprofen (Motrin®). This finding is consistent with studies involving both older adults and patients with breast cancer. A study of older adults conducted by Fowler, Durham, Planton, and Edlund (2014) concluded that the number of non-steroidal anti-inflammatory drugs (NSAIDs) older adults utilize is three times higher than the amount younger adults reportedly use. In a study of women newly diagnosed with breast cancer after primary surgery for breast cancer, Fenlon, Powers, Simmonds, Clough, and Addington-Hall (2014) discovered that 49% of women who underwent surgery for breast cancer in the prior 30-day period advocated pain relief from over-the-counter analgesia. In a study of women age 18 through 85 who were experiencing pain at least three months following breast cancer surgery, Beyaz et al. (2016) found that 59.5% controlled their pain with anti-inflammatory medications and/or simple analgesics.

As Table 3 demonstrates, at α=0.05, significant relationships were revealed between mean postoperative pain scores and cumulative postoperative opioid dosages (p<0.001); 48-hour pain scores (p=0.005); and 48-hour opioid dosages (p=0.008) and between 48-hour opioid dosages and cumulative postoperative opioid dosages (p=0.035) as well as 48-hour pain scores (p=0.001). Future analyses exploring the relationships among these variables would inform optimal pain management during the recovery periods immediately following breast surgery and following discharge to home/self-care.

Women Who Required Post-Discharge Opioid Pain Medication

The mean PACU opioid dose for the 28 study participants who required opioid pain medication following discharge was only slightly higher than that of the participants who did not (2.46 vs. 1.66 MMEs, respectively). The mean pain scores at 48 hours post-discharge were also higher at 4.21 vs. 1.9, respectively. While recovering in the PACU, seven of these women required no opioid analgesia. Within this group of 28 women, 12 endorsed requiring only one opioid tablet post-discharge. The average number of tablets required by the women in this group at this timepoint was 3.68 tablets.

Some evidence of hesitation to use opioid analgesia to optimally manage pain was noted in this group. For example, two participants who endorsed high pain scores (7/10 and 10/10 respectively) 48 hours after discharge both reported self-administering only one prescribed opioid pain tablets despite describing themselves as “in a lot of pain” and “achy, painful” at this timepoint. These examples highlight the underreporting and subsequent undertreatment of pain that is unfortunate and not uncommon among women in this age range. In their study of older adults experiencing persistent pain over a three-month period, Makris et al. (2015) found that beliefs about the age-related inevitability of pain; negative attitudes toward medications; and negative patient-provider interactions, including lack of collaboration with the patient in treatment planning, served as deterrents to study participants reaching out to providers to discuss pain relief options. The needless suffering of these two study participants while recovering at home may reflect these findings or may be a consequence of knowledge deficit concerning appropriate analgesia use in this age group.

Women Who Did Not Require Post-Discharge Opioid Analgesia

Several differences were noted between study participants requiring postoperative opioid analgesia and those who did not. Of the 29 women in this group, 17 (58.6%) did not require opioids in the PACU or during the 48-hour post-discharge period. We expected to find that the 29 women who did not take post-discharge opioids did so because of their fear of addiction, stigma, and/or adverse effects, including nausea, constipation, and somnolence. However, only one woman in this group endorsed a pain score over 4/10 during her 48-hour post-discharge telephone follow up, explaining that she was just “pretty sore” and did not fill her opioid prescription because she did not need it. Of the five next highest scorers in this group (all reported 4/10 pain), one of the women relayed that she did not need opioid analgesia post-discharge because her pain was managed so well in the PACU. A total of 13 of these 29 women actually filled their opioid prescriptions yet reported that the prescription proved unnecessary.

Findings among All Study Participants

The overall low pain scores and low dosages of opioid analgesics required for postoperative and post-discharge pain control in this population can be attributed to a number of factors. All data were collected in the same surgery centers with consistently the same surgical team who follow the same Enhanced Recovery after Surgery (ERAS) protocols. This not only provided for reliability in data collection but also served to optimize postsurgical outcomes for the participants included in this secondary analysis.

The pain experiences of older women with breast cancer during the immediate postoperative period following breast cancer surgery and again at 48 hours postoperatively were the primary focus of the present study. As multiple physiologic processes are affected by aging, older adults often experience slowed metabolism, lower distribution volumes, and higher end-organ sensitivity to anesthetic agents (Akhtar & Ramani, 2015). Thus, the 48-hour recovery period following discharge may have been inadequate to allow for older women to fully process anesthetics and other agents received during the perioperative period, resulting in lower postoperative pain scores. For example, a study by Divella et al. (2020) found that 105 of 261 women with breast cancer (48.2%) endorsed chronic pain six months following breast surgery. Because the parent study follows women with breast cancer longitudinally over the course of one year and is currently offering the opportunity for continued participation for two additional years, future studies of the pain experiences of these women across longer periods of time will be possible.

Impaired ability to metabolize anesthetic agents renders regional anesthesia an ideal consideration for older adults, as it decreases physiologic stress on patients whose physiologic reserves are already limited. Multimodal approaches to perioperative pain management that included the use of regional anesthesia have been proven to decrease opioid use and pain scores as well as improve postoperative functionality and patient satisfaction (Lin, Darling, & Tsui, 2019). While the surgical staff involved in this study do occasionally employ regional anesthesia when performing breast surgeries, none of the patients included in this secondary analysis received regional anesthesia. Future studies that compare postoperative pain levels and functionality in older adults between those who received systemic versus regional anesthesia would inform best perioperative practices for this population.

Even among the group of 28 women who did require postoperative analgesia either while in the PACU or post-discharge, opioid usage was minimal. Seven of these 28 women (25%) did not require analgesia while in the PACU, and of those who did, the average dose administered was less than 2.5 MMEs. 54% (n=15) of study participants requiring opioid analgesia post-discharge used only one or two of their prescribed opioid analgesic tablets—12 participants only required one, and three reported self-administering two tablets. Variability among opioid analgesic type was also low. Of the 21 out of 28 women in this group who required opioid analgesia in the PACU, 11 (39%) received hydromorphone alone−−14 (50%) of these 28 women who required post-discharge opioid analgesics received Norco® (hydrocodone bitartrate 5 mg combined with acetaminophen 325 mg).

Limitations

Both the parent study and this secondary analysis are nonexperimental, inherently limiting this study’s generalizability. The small overall sample size of 57 women and the fact that only 28 of these women required opioid analgesia post-discharge also contribute to the limited ability to apply this secondary study to the general population.

Although the surgical teams at both facilities included in the parent study adhere to ERAS protocols to optimize patients’ surgical outcomes, their practices may differ from other surgical groups. This may have influenced the outcomes and therefore limited generalizability to other surgery centers. The variables 48-Hour Opioid Drug Type, Number of Opioid Tablets Taken at 48 Hours, and 48-Hour Pain Scores relied on patient self-report and ability to recall facts during an often fast-paced and stressful period of study participants’ lives—thus, recall bias may have also impacted the results.

Study participants were not asked to distinguish whether the opioid pain medications they self-administered during the 48-hour period post-discharge were intended for relief of acute, postoperative pain or to alleviate pain from a chronic condition such as osteoarthritis. Another limitation of this secondary analysis was its exploration of older women’s pain experiences retrospectively, relying largely on participants’ ability to recall and self-report their perceptions of the pain at the time it occurred.

Future Studies

Recruitment continues for the parent study, which examines cancer-related symptoms that adult women with breast cancer experience during their recovery period after breast surgery to three years out from surgery. This will enable the collection of extensive symptom-related data, including pain experiences, for this age group, providing data for more secondary analyses specific to women in this cohort who are age 65 or older. A study employing qualitative interviews with select participants from the parent study who are age 65 and older to discuss their unique pain experiences will be conducted in the coming months. This will provide opportunities for this distinctive age group to discuss their personal perspectives on pain and pain management.

Our analysis revealed that 48-Hour Opioid Drug Type and PACU Opioid Type were the only two factors significantly associated with the dosage of opioid analgesia study participants required 48 hours post-discharge. Therefore, research addressing different types of preoperative medications, surgical procedures, anesthetic methods, and medications (both opioid and non-opioid) that optimize perioperative pain management should be the focus of future studies employing a larger sample of women following breast cancer surgery.

In this secondary analysis, we found that 12 of 57 older participants filled but did not use their prescribed opioid analgesics while another 12 only required one tablet. These data obviate the need for more research regarding the importance of providing education to this patient population about pain management practices, particularly safe use and handling of opioids. This should include instructing the patient and caregiver about safe disposal of unused opioids, in the event that the patient does not require all the opioid tablets prescribed for them. The website for the Diversion Control Division of the Drug Enforcement Agency (DEA) contains a search capability by postal code for drug take back locations within a five to 50-mile radius. Ensuring this website and information on the dangers of failing to properly dispose of unused opioids are included in patient discharge instructions will decrease the likelihood of diversion or being flushed down the toilet and infiltrating water supplies.

As previously mentioned, older adults tend to downplay and undertreat their pain. Therefore, evidence supporting the critical need for educating patients with cancer to notify clinicians immediately at the onset of acute pain or inability to control chronic pain should be a research priority. This education should include information regarding who to call when this pain remains unrelieved after enacting interventions or if the quantity of analgesia on hand to manage their pain is insufficient.

Nurses play an important role in assisting clinicians with optimization of the amount and type of pain medication prescribed. Conversations with patients during preoperative teaching regarding pain management practices are absolutely vital. More research that provides guidance for nurses and clinicians with the challenges associated with balancing adequate postoperative pain control with prescribing the appropriate type and amount of oral analgesics for patients to take at home could mitigate this problem.

Research supporting the importance of preoperative discussions with older adult patients involving their medical and medication histories, including the reasons any medications were discontinued; tolerance and efficacy of pain medications they have taken in the past; and current analgesic practices for conditions such as osteoarthritis that are common in this patient population will facilitate the prescription of postoperative pain management plans that are both safe and efficacious. For example, older adults with liver failure will require restricted use of acetaminophen and opioids, while those with kidney failure may need to avoid or limit the use of NSAIDs, including Toradol® (ketorolac), for pain relief. Gathering complete medication and pain histories will also decrease the likelihood that duplicate medications or medications in the same drug class will be prescribed and aid in preventing possible adverse effects of opioid analgesia, including accidental opioid overdose. This research should also highlight that provision of thorough patient education regarding postoperative pain management empowers older adults with cancer to adequately manage their pain, resulting in maximum quality of life and decreased development of debility.

Studies that reflect the efficacy of nurse-led protocol development of pain interventions among their perioperative care teams will promote consistency in pain control practices for older adults. These protocols should accommodate patients for whom standardized pain management protocols would be dangerous. For example, if a patient will resume prescribed anticoagulant therapy after discharge and is going home with surgical drains in place, it may be prudent to avoid postoperative use of NSAIDs to decrease the likelihood of postsurgical bleeding.

Conclusions

Among all the characteristics explored in this secondary analysis, only the type of opioids received while in the PACU and 48 hours after discharge emerged as being associated with the amount of opioid analgesia required by older women following discharge after breast cancer surgery. This study demonstrated that postoperative pain was generally well-controlled in this sample of older women during their PACU stay and 48 hours following discharge. More than half of the women involved in this study chose not to employ opioid analgesia to manage postoperative pain. Future studies that explore the reasons older women choose not to employ opioid analgesia for pain management and the factors that contribute to optimal pain management will improve quality of life for older women with breast cancer from diagnosis through survivorship to end-of-life care.

Highlights.

• Older adults tend to undertreat and underrate pain, leading to chronic pain and low quality of life.

• Postoperative opioid use was low in this sample of older women with early-stage breast cancer.

• Excellent patient education empowers older adults to manage their pain safely and effectively.