Division of Female Pelvic Medicine and Reconstructive Surgery, Hartford Hospital, Hartford, CT.
Department of Research Administration, Hartford Healthcare, Hartford, CT.
Am J Obstet Gynecol. 2020 Aug;223(2):262.e1-262.e8. doi: 10.1016/j.ajog.2020.05.019. Epub 2020 May 13.
Postoperative opioid prescription patterns play a key role in driving the opioid epidemic. A comprehensive system toward pain management in surgical patients is necessary to minimize overall opioid consumption.
This study aimed to evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring postdischarge narcotic use in morphine milligram equivalents.
This is a prospective clinical practice study that included women undergoing inpatient pelvic reconstructive surgery from December 2018 to June 2019 with overnight stay after surgery. As a routine protocol, all the patients followed an enhanced recovery after surgery protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory surveys were collected preoperatively and on postoperative day 1. Brief pain inventory and activities assessment scale scores were collected at postoperative week 1 and postoperative weeks 4-6 after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription for controlled substances software platform, which is mandated in the state of Connecticut for all controlled substances, prescriptions, and refills. Patients were called at postoperative week 1 and postoperative weeks 4-6 to answer questions regarding their pain, the number of remaining narcotic tablets, and patient satisfaction regarding pain management. Patient electronic medical records and the Connecticut Prescription Monitoring and Reporting System were reviewed to determine whether patients received narcotic refills. Primary outcome was postdischarge narcotic use measured in morphine milligram equivalents. Secondary outcomes evaluated refill rate, brief pain inventory and activities assessment scale scores, and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range. Bivariate comparisons used Spearman's rho (ρ) with α=0.05.
A total 113 patients were enrolled; the median (interquartile range) morphine milligram equivalent prescribed (including refills) was 112.5 (112.5-112.5). The median postdischarge narcotic use was 24.0 (0-82.5) morphine milligram equivalent, which is equivalent to fewer than 4 oxycodone (5 mg) tablets. About 75% of our participants required fewer than 11 oxycodone tablets. The median unused morphine milligram equivalent was 90.0 (45-112.5). 81.4% (92/113), and 83.2% (94/113) of patients at postoperative week 1 and postoperative weeks 4-6, respectively, reported being satisfied or extremely satisfied with their postdischarge pain control. About 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the postoperative 1 and postoperative weeks 4-6 time points. At postoperative weeks 4-6, 19.5% of patients said that they filled the narcotic prescription but did not use any of the pills. The overall refill rate was 10.6% (12/113). All patients who needed a refill described the refill process as easy. In-hospital narcotic use was not predictive of postdischarge narcotic use (ρ0.065, P=.495). Patients reported median brief pain inventory scores for "average pain" of 0 (no pain) at postoperative week 1 and postoperative weeks 4-6; however, the scores did not clinically correlate with postdischarge narcotic use. Activities assessment scale scores were not correlated with postdischarge narcotic use.
Most patients after pelvic reconstructive surgery used fewer than 11 oxycodone (5 mg) tablets, averaging less than 4 tablets, with a third of patients not requiring any opioids. Pain and activities scores did not correlate with narcotic use. A minimal number of opioids can be prescribed because the secure electronic prescribing system allows for convenient electronic refill if required. Our practical and comprehensive pre- and postoperative protocol for pain management minimizes opioid consumption in addition to maximizing patient satisfaction.
术后阿片类药物处方模式在推动阿片类药物流行方面发挥着关键作用。为了最大限度地减少整体阿片类药物的消耗，有必要为手术患者建立一个全面的疼痛管理系统。
本研究旨在通过测量出院后阿片类药物的吗啡毫克当量来评估一种疼痛管理模式在接受骨盆重建手术的患者中的疗效。
这是一项前瞻性临床实践研究，包括 2018 年 12 月至 2019 年 6 月期间接受住院骨盆重建手术的女性患者，术后需过夜。作为常规方案，所有患者均遵循增强型术后康复方案，包括术前多模式疼痛方案。在术前和术后第 1 天采集简短疼痛量表调查。在术后第 1 周和术后第 4-6 周采集简短疼痛量表和活动评估量表评分。患者出院时凭电子处方获得 15 片口服阿片类药物，该处方是康涅狄格州所有受控物质、处方和续方的强制性要求。在术后第 1 周和术后第 4-6 周，患者会接到电话询问他们的疼痛情况、剩余阿片类药物片剂的数量以及他们对疼痛管理的满意度。查阅患者的电子病历和康涅狄格州处方监测和报告系统，以确定患者是否收到阿片类药物的续方。主要结局是出院后阿片类药物的使用，以吗啡毫克当量衡量。次要结局包括续方率、简短疼痛量表和活动评估量表评分以及患者对疼痛管理的满意度。描述性统计采用均值和标准差以及中位数和四分位距表示。采用 Spearman rho（ρ）进行双变量比较，α=0.05。
共纳入 113 例患者；中位数（四分位距）开出处方（包括续方）吗啡毫克当量为 112.5（112.5-112.5）。出院后阿片类药物的中位数使用量为 24.0（0-82.5）吗啡毫克当量，相当于不到 4 片羟考酮（5mg）。约 75%的参与者需要的羟考酮少于 11 片。中位数未使用的吗啡毫克当量为 90.0（45-112.5）。81.4%（92/113）和 83.2%（94/113）的患者分别在术后第 1 周和术后第 4-6 周报告对出院后疼痛控制满意或非常满意。约 88.5%（100/113）的患者认为在术后第 1 周和术后第 4-6 周，他们出院时携带的阿片类药物数量足以满足他们的疼痛需求。在术后第 4-6 周，19.5%的患者表示他们开了阿片类药物的处方，但没有使用任何一片。总体续方率为 10.6%（12/113）。所有需要续方的患者都表示续方过程很容易。住院期间的阿片类药物使用与出院后阿片类药物使用无关（ρ=0.065，P=0.495）。患者在术后第 1 周和术后第 4-6 周报告的“平均疼痛”简短疼痛量表得分为 0（无疼痛）；然而，这些评分与出院后阿片类药物使用无临床相关性。活动评估量表评分与出院后阿片类药物使用无关。
大多数骨盆重建手术后的患者使用的羟考酮少于 11 片（5mg），平均少于 4 片，三分之一的患者不需要任何阿片类药物。疼痛和活动评分与阿片类药物使用无关。由于安全的电子处方系统允许在需要时方便地进行电子续方，因此可以开具较少数量的阿片类药物。我们实用且全面的围手术期疼痛管理方案不仅最大限度地提高了患者的满意度，还最大限度地减少了阿片类药物的消耗。
