Opioid-Sparing Multimodal Analgesia Protocol for Lumpectomy Patients Results in Superior Postoperative Pain Control.
Journal
Annals of surgical oncology
ISSN: 1534-4681
Titre abrégé: Ann Surg Oncol
Pays: United States
ID NLM: 9420840
Informations de publication
Date de publication:
Oct 2021
Oct 2021
Historique:
received:
29
01
2021
accepted:
03
03
2021
pubmed:
3
6
2021
medline:
28
9
2021
entrez:
2
6
2021
Statut:
ppublish
Résumé
We sought to determine if lumpectomy patients who received perioperative opioid-sparing multimodal analgesia reported less pain when compared with those who received traditional opioid-based care. A prospective cohort of patients undergoing lumpectomy who received an opioid-sparing multimodal analgesia protocol [no opioids group (NOP)] was compared with a large cohort of patients who received traditional care [opioids group (OG)]. In-hospital and discharge opioids were compared using oral morphine equivalents (OMEs). Postoperative day one and week one pain scores were compared using the Kruskal-Wallis test. Overall, 1153 patients underwent lumpectomy: 634 patients received the protocol (NOP), and 519 patients did not (OG). Median pain scores were significantly lower in the NOP cohort when compared with the OG cohort the day after surgery (2 vs. 0, p < 0.001) and the week after surgery (1 vs. 0, p < 0.001). NOP patients were significantly less likely to report severe pain (7-10 on a 10-point scale) the day after surgery compared with OG patients (15.7% vs. 6.9%, p = 0.004). Patients in the NOP cohort were discharged with a median of zero OMEs (range 0-150), while patients in the OG were discharged with a median of 90 OMEs (range 0-360; p < 0.001). Implementation of an opioid-sparing multimodal analgesia protocol for lumpectomy patients resulted in superior pain control without a routine opioid prescription. Surgeons can improve their own patients' outcomes while addressing the larger societal issue of the opioid crisis by adopting similar protocols that decrease the quantity of opioids available for diversion.
Sections du résumé
BACKGROUND
BACKGROUND
We sought to determine if lumpectomy patients who received perioperative opioid-sparing multimodal analgesia reported less pain when compared with those who received traditional opioid-based care.
STUDY DESIGN
METHODS
A prospective cohort of patients undergoing lumpectomy who received an opioid-sparing multimodal analgesia protocol [no opioids group (NOP)] was compared with a large cohort of patients who received traditional care [opioids group (OG)]. In-hospital and discharge opioids were compared using oral morphine equivalents (OMEs). Postoperative day one and week one pain scores were compared using the Kruskal-Wallis test.
RESULTS
RESULTS
Overall, 1153 patients underwent lumpectomy: 634 patients received the protocol (NOP), and 519 patients did not (OG). Median pain scores were significantly lower in the NOP cohort when compared with the OG cohort the day after surgery (2 vs. 0, p < 0.001) and the week after surgery (1 vs. 0, p < 0.001). NOP patients were significantly less likely to report severe pain (7-10 on a 10-point scale) the day after surgery compared with OG patients (15.7% vs. 6.9%, p = 0.004). Patients in the NOP cohort were discharged with a median of zero OMEs (range 0-150), while patients in the OG were discharged with a median of 90 OMEs (range 0-360; p < 0.001).
CONCLUSION
CONCLUSIONS
Implementation of an opioid-sparing multimodal analgesia protocol for lumpectomy patients resulted in superior pain control without a routine opioid prescription. Surgeons can improve their own patients' outcomes while addressing the larger societal issue of the opioid crisis by adopting similar protocols that decrease the quantity of opioids available for diversion.
Identifiants
pubmed: 34076809
doi: 10.1245/s10434-021-09963-3
pii: 10.1245/s10434-021-09963-3
pmc: PMC8170864
doi:
Substances chimiques
Analgesics, Opioid
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
5855-5864Informations de copyright
© 2021. Society of Surgical Oncology.
Références
American Cancer Society. Breast cancer facts and figures 2019–2020. Atlanta: American Cancer Society, Inc.; 2019.
Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017;265(4):709–14.
pubmed: 27631771
doi: 10.1097/SLA.0000000000001993
pmcid: 27631771
Compton WM, Boyle M, Wargo E. Prescription opioid abuse: problems and responses. Prev Med. 2015;80:5–9.
pubmed: 25871819
doi: 10.1016/j.ypmed.2015.04.003
pmcid: 25871819
Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13:e58–68.
pubmed: 22300860
doi: 10.1016/S1470-2045(12)70040-2
pmcid: 22300860
Vella-Brincat J, Macleod AD. Adverse effects of opioids on the central nervous systems of palliative care patients. J Pain Palliat Care Pharmacother. 2007;21(1):15–25.
pubmed: 17430825
doi: 10.1080/J354v21n01_05
pmcid: 17430825
Rojas K, Fortes T, Flom P, et al. Intraoperative ketorolac use does not increase the risk of bleeding in breast surgery. Ann Surg Oncol. 2019;26(10):3368–73.
pubmed: 31342387
doi: 10.1245/s10434-019-07557-8
pmcid: 31342387
Rojas K, Manasseh DM, Flom PL, et al. A pilot study of a breast surgery enhanced recovery after surgery (ERAS) protocol to eliminate narcotic prescription at discharge. Breast Cancer Res Treat. 2018;171(3):621–6.
pubmed: 29915947
doi: 10.1007/s10549-018-4859-y
pmcid: 29915947
Rojas K, Fortes TA, Flom PL, et al. Mastectomy is no longer an indication for postoperative opioid prescription at discharge. Am J Surg. 2019;218(4):700–5.
pubmed: 31350009
doi: 10.1016/j.amjsurg.2019.07.017
pmcid: 31350009
Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.
pubmed: 18929686
doi: 10.1016/j.jbi.2008.08.010
pmcid: 18929686
Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software partners. J Biomed Inform. 2019;95:103208.
pubmed: 31078660
pmcid: 7254481
doi: 10.1016/j.jbi.2019.103208
Guideline Resources: CDC Opioid Guideline Mobile App. http://www.CDC.gov . 29 July 2019.
Peuckmann V, Ekholm O, Rasmussen NK, et al. Chronic pain and other sequelae in long- term breast cancer survivors: nationwide survey in Denmark. Eur J Pain. 2009;13(5):478–85.
pubmed: 18635381
doi: 10.1016/j.ejpain.2008.05.015
pmcid: 18635381
Moreno M, Wiltgen JE, Bodanese B, et al. Radioguided breast surgery for occult lesion localization—correlation between two methods. J Exp Clin Cancer Res. 2008;27:29.
pubmed: 18706096
pmcid: 2531080
doi: 10.1186/1756-9966-27-29
Moo TA, Assel M, Yeahia R, Nierstedt R, et al. Routine opioid prescriptions are not necessary after breast excisional biopsy or lumpectomy procedures. Ann Surg Oncol. 2021;28(1):303–9.
pubmed: 32588263
doi: 10.1245/s10434-020-08651-y
pmcid: 32588263
Tasmuth T, Kataja M, Blomqvist C, et al. Treatment-related factors predisposing to chronic pain in patients with breast cancer: a multivariate approach. Acta Oncol. 1997;36:625–30.
pubmed: 9408154
doi: 10.3109/02841869709001326
pmcid: 9408154
Macrae WA. Chronic pain after surgery. Br J Anaesth. 2001;87:88–98.
pubmed: 11460816
doi: 10.1093/bja/87.1.88
pmcid: 11460816
Perkins FM, Kehlet H. Chronic pain as an outcome of surgery: a review of predictive factors. Anesthesiology. 2000;93:1123–33.
pubmed: 11020770
doi: 10.1097/00000542-200010000-00038
pmcid: 11020770
Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362:1921–8.
pubmed: 14667752
doi: 10.1016/S0140-6736(03)14966-5
pmcid: 14667752
Hamood R, Hamood H, Merhasin I, Keinan-Boker L. Chronic pain and other symptoms among breast cancer survivors: prevalence, predictors, and effects on quality of life. Breast Cancer Res Treat. 2018;167(1):157–69.
pubmed: 28861642
doi: 10.1007/s10549-017-4485-0
pmcid: 28861642
Gahm J, Wickman M, Brandberg Y. Bilateral prophylactic mastectomy in women with inherited risk of breast cancer—prevalence of pain and discomfort, impact on sexuality, quality of life and feelings of regret two years after surgery. Breast. 2010;19(6):462–9.
pubmed: 20605453
doi: 10.1016/j.breast.2010.05.003
pmcid: 20605453
Verbelen H, Tjalma W, Meirte J, Gebruers N. Long-term morbidity after a negative sentinel node in breast cancer patients. Eur J Cancer Care (Engl). 2019;28(5):e13077.
doi: 10.1111/ecc.13077
Lee JS, Hu HM, Edelman AL, et al. New persistent opioid use among patients with cancer after curative-intent Surgery. J Clin Oncol. 2017;35:4042–9.
pubmed: 29048972
pmcid: 5736238
doi: 10.1200/JCO.2017.74.1363
Antao L, Shaw L, Ollson K, et al. Chronic pain in episodic illness and its influence on work occupations: a scoping review. Work. 2013;44(1):11–36.
pubmed: 23142918
doi: 10.3233/WOR-2012-01559
pmcid: 23142918
Lötsch J, Ultsch A, Kalso E. Data-science-based subgroup analysis of persistent pain during 3 years after breast cancer surgery: a prospective cohort study. Eur J Anaesthesiol. 2020;37(3):235–46.
pubmed: 32028289
doi: 10.1097/EJA.0000000000001116
pmcid: 32028289
Paice JA. Cancer pain management and the opioid crisis in America: How to preserve hard-earned gains in improving the quality of cancer pain management. Cancer. 2018;124(12):2491–7.
pubmed: 29499072
doi: 10.1002/cncr.31303
pmcid: 29499072
Leppert W. The impact of opioid analgesics on the gastrointestinal tract function and the current management possibilities. Contemp Oncol. 2012;16(2):125–31.
Taylor B, Corder G. Endogenous analgesia, dependence, and latent pain sensitization. Curr Top Behav Neurosci. 2014;20:283–325.
pubmed: 25227929
pmcid: 4464817
doi: 10.1007/7854_2014_351
Byrne K, Levins KJ, Buggy DJ. Can anesthetic-analgesic technique during primary cancer surgery affect recurrence or metastasis? Can J Anaesth. 2016;63:184–92.
pubmed: 26497721
doi: 10.1007/s12630-015-0523-8
pmcid: 26497721
Shavit Y, Ben-Eliyahu S, Zeidel A, Beilin B. Effects of fentanyl on natural killer cell activity and on resistance to tumor metastasis in rats. Dose and timing study. Neuroimmunomodulation. 2004;11:255–60.
pubmed: 15249732
doi: 10.1159/000078444
pmcid: 15249732
Aich A, Gupta P, Gupta K. Could perioperative opioid use increase the risk of cancer progression and metastases? Int Anesthesiol Clin Fall. 2016;54(4):e1–16.
doi: 10.1097/AIA.0000000000000112
Nguyen J, Luk K, Vang D, et al. Morphine stimulates cancer progression and mast cell activation and impairs survival in transgenic mice with breast cancer. Br J Anaesth. 2014;113(Suppl 1):i4-13.
pubmed: 24861561
pmcid: 4111281
doi: 10.1093/bja/aeu090
Gupta K, Kshirsagar S, Chang L, et al. Morphine stimulates angiogenesis by activating proangiogenic and survival-promoting signaling and promotes breast tumor growth. Cancer Res. 2002;62:4491–8.
pubmed: 12154060
pmcid: 12154060
Farooqui M, Li Y, Rogers T, et al. COX-2 inhibitor celecoxib prevents chronic morphine- induced promotion of angiogenesis, tumour growth, metastasis and mortality, without compromising analgesia. Br J Cancer. 2007;97:1523–31.
pubmed: 17971769
pmcid: 2360252
doi: 10.1038/sj.bjc.6604057
Cummings K, Xu F, Cummings L, Cooper G. A comparison of epidural analgesia and traditional pain management effects on survival and cancer recurrence after colectomy: a population-based study. Anesthesiology. 2012;116(4):797–806.
pubmed: 22273991
doi: 10.1097/ALN.0b013e31824674f6
pmcid: 22273991
Maher D, Wong W, White P, et al. Association of increased postoperative opioid administration with non-small-cell lung cancer recurrence: a retrospective analysis. Br J Anaesthesia. 2014;113(1):i88–94.
doi: 10.1093/bja/aeu192
Cata J, Keerty V, Keerty D, et al. A retrospective analysis of the effect of intraoperative opioid dose on cancer recurrence after non-small cell lung cancer resection. Cancer Med. 2014;3(4):900–8.
pubmed: 24692226
pmcid: 4303157
doi: 10.1002/cam4.236
Janku F, Johnson L, Karp D, et al. Treatment with methylnaltrexone is associated with increased survival in patients with advanced cancer. Ann Oncol. 2016;27(11):2032–8.
pubmed: 27573565
pmcid: 6267944
doi: 10.1093/annonc/mdw317
Węgorowski P, Stanisławek A, Domżał-Drzewicka R, et al. The effect of pre-emptive analgesia on the level of postoperative pain in women undergoing surgery for breast neoplasm. Contemp Oncol (Pozn). 2016;20(2):158–64.
pubmed: 27358596
pmcid: 4925736
Przesmycki K, Wiater-Kozioł E, Kotarski J, et al. Effect of pre-emptive pregabalin on pain intensity and morphine requirement after hysterectomy. Anestezjol Intens Ter . 2011;43(1):14–7.
pubmed: 21786524
pmcid: 21786524
Priya V, Divatia JV, Sareen R, Upadhye S. Efficacy of intravenous ketoprofen for pre- emptive analgesia. J Postgrad Med . 2002;48(2):109–12.
pubmed: 12215691
pmcid: 12215691
Raja DC, Shetty AP, Subramanian B, et al. A prospective randomized study to analyze the efficacy of balanced pre-emptive analgesia in spine surgery. Spine J. 2019;19(4):569–77.
doi: 10.1016/j.spinee.2018.10.010
Sarakatsianou C, Theodorou E, Georgopoulou S, et al. Effect of pre-emptive pregabalin on pain intensity and postoperative morphine consumption after laparoscopic cholecystectomy. Surg Endosc. 2013;27(7):2504–11.
pubmed: 23344509
doi: 10.1007/s00464-012-2769-3
pmcid: 23344509
Legeby M, Sandelin K, Wickman M, Olofsson C. Analgesic efficacy of diclofenac in combination with morphine and paracetamol after mastectomy and immediate breast reconstruction. Acta Anaesthesiol Scand. 2005;49(9):1360–6.
pubmed: 16146476
doi: 10.1111/j.1399-6576.2005.00811.x
pmcid: 16146476
Güç E, Pollard J. Dampening the fire to prevent surgery- and chemotherapy-induced metastasis. J Clin Invest. 2019;129(7):2663–5. https://doi.org/10.1172/JCI129705 .
doi: 10.1172/JCI129705
pubmed: 31205029
pmcid: 6597206
Tsujii M, Kawano S, Tsuji S, Sawaoka H, Hori M, DuBois RN. Cyclooxygenase regulates angiogenesis induced by colon cancer cells. Cell. 1998;93(5):705–16.
pubmed: 9630216
doi: 10.1016/S0092-8674(00)81433-6
pmcid: 9630216
Panigrahy D, Gartung A, Yang J, et al. Preoperative Stimulation of resolution and inflammation blockade eradicates micrometastases. J Clin Invest. 2019;129(7):2964–79.
pubmed: 31205032
pmcid: 6597207
doi: 10.1172/JCI127282
Forget P, Vandenhende J, Berliere M, et al. Do intraoperative analgesics influence breast cancer recurrence after mastectomy? A retrospective analysis. . Anesth Analg. 2010;110(6):1630–5.
pubmed: 20435950
doi: 10.1213/ANE.0b013e3181d2ad07
pmcid: 20435950
Desmedt C, Demicheli R, Fornili M, et al. Potential benefit of intra-operative administration of ketorolac on breast cancer recurrence according to the patient’s body mass index. J Natl Cancer Inst. 2018;110(10):1115–22.
pubmed: 29718396
doi: 10.1093/jnci/djy042
pmcid: 29718396
Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics; 2020.
Issue brief: Reports of increases in opioid-related overdose and other concerns during the COVID pandemic. American Medical Association Advocacy Resource Center. https://www.ama-assn.org/system/files/2020-09/issue-brief-increases-in-opioid-related-overdose.pdf . Accessed 2 Oct 2020.
Volkow N, McLellan T. Opioid abuse in chronic pain- misconceptions and mitigation strategies. New Engl J Med. 2016;374:1253–63.
pubmed: 27028915
doi: 10.1056/NEJMra1507771
pmcid: 27028915
Shei A, Rice JB, Kirson NY, et al. Sources of prescription opioids among diagnosed opioid abusers. Curr Med Res Opin. 2015;31:779–84.
pubmed: 25661018
doi: 10.1185/03007995.2015.1016607
pmcid: 25661018
Gartner R, Jensen MB, Nielsen J, et al. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302(18):1985–92.
pubmed: 19903919
doi: 10.1001/jama.2009.1568
pmcid: 19903919
Katz J, Poleshuck EL, Andrus CH, et al. Risk factors for acute pain and its persistence following breast cancer surgery. Pain. 2005;119(1–3):16–25.
pubmed: 16298063
doi: 10.1016/j.pain.2005.09.008
pmcid: 16298063
Wang L, Guyatt GH, Kennedy SA, et al. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies. CMAJ. 2016;188(14):E352–61.
pubmed: 27402075
pmcid: 5047835
doi: 10.1503/cmaj.151276
Morin C, Javid M, Patel Y, et al. Obese patients who receive an opioid-sparing enhanced recovery after surgery (ERAS) protocol are at increased risk of persistent pain after breast surgery. Ann Surg Oncol. 2020;27:4802–9.
pubmed: 32749623
doi: 10.1245/s10434-020-08894-9
pmcid: 32749623
Divella M, Vetrugno L, Bertozzi S, Seriau L, Carla C, Bove T. Patient-reported pain and other symptoms among breast cancer survivors: prevalence and risk factors. Tumori. 2020;106(6):480–90.
pubmed: 32162594
doi: 10.1177/0300891620908930
pmcid: 32162594