Just Say No: The Case Against Opioid-Based Postoperative Pain Management Regimens Following Breast Surgery

Abstract

Despite losing coverage in the headlines and priority among legislators due to the COVID-19 global health pandemic, the opioid crisis continues to wreak havoc across the country. Nearly 71,000 drug overdose deaths were reported by the Centers for Disease Control (CDC) in 2019, with over 50,000 of these deaths involving opioids. It can trace its roots to the early 1990s when financial, ethical, and regulatory pressures, as well as false reassurances from pharmaceutical companies regarding the addictive nature of opioids, resulted in the encouragement of liberal use of opioids to control pain. The opioid epidemic blossomed due to altruistic efforts by physicians and surgeons attempting to provide compassionate patient care. The increased use of opioids subsequently resulted in widespread diversion and misuse, and current data suggest that 80% of people who use heroin first misused prescription opioids. This trend is both deadly and expensive. The CDC estimates that the total economic burden of prescription opioid misuse alone in the USA is US$78.5 billion per year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. For many patients addicted to opioids, filling a prescription after an operation was where it all began. Approximately 6% of previously opioid-naı̈ve patients continue to use opioids more than 3 months after an operation. Without data to guide management of acute postoperative pain, most patients are prescribed more narcotics than necessary. In a systematic review of 810 postoperative patients in 2017, 67–92% reported unused opioids. The vast majority (around 75%) of these patients stored the extra opioids in unlocked locations, and less than 10% were discarded according to an appropriate disposal method, offering unlimited opportunities for diversion. Since the opioid epidemic was declared a public health emergency in 2017, priority has been placed on developing evidence-based strategies to both adequately treat postoperative acute pain and mitigate the consequences and side effects of the treatment provided. In this issue of Annals of Surgical Oncology, Morin et al. add to the growing body of literature supporting nonopioid-based regimens for postoperative pain management following breast surgery. In their nonrandomized study, postoperative pain scores were compared amongst two cohorts of patients undergoing partial mastectomies—those who received an opioid-sparing regimen as part of a prospective pilot study (operation performed September 2017 to April 2019) and historical patients who were discharged with an opioid-based regimen (operation performed July 2015 to June 2016). The opioid-sparing regimen included preoperative education, gabapentin and acetaminophen given in holding, intraoperative liposomal bupivacaine and ketorolac, as well as postoperative acetaminophen and ibuprofen. They excluded patients with history of opioid dependence or chronic use as well as patients undergoing mastectomy or axillary surgery alone. Patients in the opioid-sparing group reported statistically significantly less pain on postoperative day 1 than patients in the traditional opioid group: 19.1% versus 34.3% reported moderate pain (p \\ 0.001), and 6.9% versus 15.7% reported severe pain (p = 0.004). By postoperative day 7, the opioid-sparing group still reported less pain, but it did not reach statistical significance. The authors Society of Surgical Oncology 2021