The overall complication rate was 9.5 percent (n = 9), which was similar between groups [secondary breast reconstruction, n = 6 (10.3 percent); breast reduction, n = 3 (8.9 percent)] (Table 3). There was no significant difference between responders and nonresponders for any of the demographic or clinical variables for both the secondary breast reconstruction and breast reduction groups. All patients included had preoperative Pain, Enjoyment, General Activity survey data that were also similar between the postoperative responders and nonresponders.
Pain, Enjoyment, General Activity Survey Results
Inclusive of all patients, the mean pain score preoperatively was 2.81 (Fig. 3). There was a slight increase to 4.81 at postoperative days 3 to 5, followed by a decrease to 3.59 at postoperative days 8 to 10. At greater than postoperative day 30, the mean pain score was 3.00. When asked how pain interfered with enjoyment, the average preoperative score was 2.22, with an increase to 4.11 on postoperative days 3 to 5. The mean score stayed at 4.81 at the conclusion of the study. Similarly, the mean score for how pain affected general activity was 2.4 preoperatively. At postoperative days 3 to 5, the average score was 4.75, which was stable at 5.06 on postoperative day 30.
Secondary Breast Reconstruction Group
The mean preoperative pain score for the secondary breast reconstruction patients was 1.95 (Fig. 4). Patients that reported taking any of the opioids prescribed had significantly higher preoperative pain scores than those that did not (2.41 versus 0.10; p = 0.008). Patients reported increased pain at postoperative days 3 to 5 (score, 4.69). At postoperative days 8 to 10, the average pain score was 3.32, which was similar at postoperative day 30 (score, 3.28). The secondary breast reconstruction patients also had very mild pain scores for how pain interfered with enjoyment (score, 1.40) and general activity (score, 1.62) preoperatively. At postoperative day 30, the mean score was 4.77 for how pain interfered with enjoyment and 5.08 for how pain interfered with general activity.
When the secondary breast reconstruction group was stratified by procedure type, there was no significant difference in the mean number of opioid tablets left over at postoperative day greater than 30 and primary procedure (p = 0.931) (Table 4). The postoperative Pain, Enjoyment, General Activity survey scores were also similar among all procedures for all three time points (postoperative days 3 to 5, p = 0.240; postoperative days 8 to 10, p = 0.678; postoperative day greater than 30, p = 0.752). In addition, there was no significant difference between Pain, Enjoyment, General Activity survey scores and the number of procedures performed.
Breast Reduction Group
For the breast reduction group, the preoperative pain score was 4.24 (Fig. 5). There was not a significant difference in preoperative pain scores between patients that did and did not take opioid medication (p = 0.176). After a slight increase to 5.10 on postoperative days 3 to 5, the mean score at postoperative days 8 to 10 was 4.33. This further declined to 1.40 at postoperative day 30. When asked how pain interfered with enjoyment and general activity, the mean score preoperatively was 3.58 and 3.70, respectively, but the mean score at postoperative day 30 for both was 0.60.
Pain Medication Use
At the conclusion of the study, 75.0 percent of secondary breast reconstruction patients (n = 36 of 48) and 72.0 percent of breast reduction patients (n = 18 of 25) took at least one opioid tablet (Table 5). Patients reported taking opioids for 8.5 days after secondary breast reconstruction and 11.1 days after a breast reduction. The most common reason for discontinuing the opioid medication was that pain was well controlled (secondary breast reconstruction, 71.4 percent; breast reduction, 73.9 percent). At postoperative day 30, 7.1 percent of the secondary breast reconstruction patients were still taking opioid medications, whereas none of the breast reduction patients were. For those that discontinued opioids, a mean of 18.6 tablets were left over in the secondary breast reconstruction group and a mean of 12.5 (range, zero to 26) tablets were left over in the breast reduction group (range, zero to 29).
The majority of patients used over-the-counter supplemental pain medication (secondary breast reconstruction, 77.1 percent; breast reduction, 64.0 percent). The most common was any of the nonsteroidal antiinflammatory medications. There was not a significant difference in Pain, Enjoyment, General Activity survey scores between patients that used supplemental medications and those that did not for the breast reduction group. In the secondary breast reconstruction group, patients that used supplements had a mean pain score of 5.09 versus 1.33 for those that did not on postoperative days 3 to 5. There was no significant difference in Pain, Enjoyment, General Activity survey scores for any other time points.
By postoperative day 30, 38.3 percent of the secondary breast reconstruction patients and 53 percent of the breast reduction patients reported experiencing side effects from opioids. Opioids were discontinued because of side effects in 16 percent (secondary breast reconstruction) and 9.1 percent (breast reduction). The most common side effect experienced was difficulty sleeping and/or bad dreams (secondary breast reconstruction, 58.8 percent; breast reduction, 50.0 percent).
The majority of patients reported that they were very satisfied with their pain management (secondary breast reconstruction, 79.5 percent; breast reduction, 80.0 percent) (Table 6). Similarly, most were very satisfied with how long it took to feel normal and definitely agreed that, overall, surgery was a positive experience (secondary breast reconstruction, 83.3 percent; breast reduction, 92.0 percent) and would do it again. Furthermore, most patients definitely agreed that they had no regrets about undergoing surgery.
The overprescribing of opioids is a national epidemic, with physicians poised to help limit the abuse, misuse, and overabundance of opioids on the market. Because of the lack of guidelines, physicians are led to believe that more is better, often giving patients extra medication “just in case.”11 , 12 Without the ability to “call in” more opioids if needed, many physicians feel they should give all patients an excessive number in case they run out at night or on the weekend. At our institution, we assented to this dogma that more medication was equal to better pain control and satisfaction. In this report, 95 patients received a single prescription of 30 opioid tablets after ambulatory surgery. The postoperative pain scores were low, and patients felt pain management met expectations. Our results echo those from other reports of ambulatory orthopedic and hand surgery practices that show leftover opioid tablets after minor surgical procedures.11 , 12 As a group, surgeons are often overprescribing opioids to patients, leading to a large number of leftover opioids in circulation.
According to our results, most patients had 12 to 18 leftover tablets. For many patients, an excessive number of narcotics were given without a proven benefit. Interestingly, 7.1 percent of secondary breast reconstruction patients were still taking opioids intermittently at greater than postoperative day 30. Because the pain scores following secondary breast reconstruction had trended back down to 3, it is unlikely that patients were still experiencing excessive pain. Many patients receive their first exposure to opioids after surgery. However, the absolute risk of new and persistent opioid abuse after surgical procedures has not been defined. In a cohort of 29,068 patients by Brummett et al., the authors found that following minor surgical procedures, 5.9 percent of patients filled an opioid prescription postoperatively, with a mean of three new prescriptions and over 200 pills per patient.13 In their analysis, tobacco use, alcohol abuse, anxiety, and mood disorders were independently associated with an increased risk for persistent opioid use in opioid-naive patients. Another recent study by Sekhri et al. evaluated 26,000 opioid-naive surgery patients to determine what percentage of patients refilled their prescription within 30 days.14 The authors found that 8.67 percent of patients refilled their prescriptions, but the probability of refill was not related to the amount given. Instead, across all procedures, the probability of obtaining a single refill was related to patient factors such as tobacco use, anxiety, and mood disorders. Although we did not evaluate the level of anxiety or mood symptoms in the secondary breast reconstruction patients, it has been previously shown that breast cancer patients are at increased risk of anxiety and depression often associated with the diagnosis of breast cancer.15 Elevated levels of anxiety have also been linked to increased risk for narcotic overuse and abuse.15 Although we cannot conclude that mood symptoms are related to the continued use of opioids, it is interesting that all of the breast reduction patients stopped all narcotics by greater than postoperative day 30, whereas 7.1 percent of the secondary breast reconstruction patients continued to use narcotics.
Furthermore, previous reports have shown that breast cancer surgery results in persistent moderate to severe pain in 15 to 20 percent of women.16 The persistence of pain after breast cancer surgery has been determined to be multifactorial and often related to preoperative risk factors such as elevated body mass index, axillary lymph node dissection, and other psychosocial factors.16 In an attempt to develop a clinical risk assessment tool, a recent analysis of three large cohorts of women was used to more clearly define risk factors for persistence of pain after breast cancer surgery. This analysis showed that higher postoperative pain scores were associated with persistence of pain greater than 1 year postoperatively. Most interestingly, the secondary breast reconstruction group was more likely to report that pain interfered with enjoyment and activity at a moderate level (4 to 5 of 10) despite having relatively low pain scores at the same time points. Perhaps these patients continue to experience persistent pain and anxiety above what is to be expected from the minor surgical procedure as a result of their original breast cancer surgery and not related to the acute postsurgical pain.17 Although our analysis excluded patients with a history of chronic pain, it is plausible that, following breast cancer surgery, women have a heightened sense of pain related to the experience of breast cancer and reconstruction.17 , 18 As the risk factors for persistent pain after breast surgery coincide with the risks for developing problems with long-term opioid use after surgery, perhaps opioid medications are not the best method for pain management after secondary breast reconstruction. The use of models such as those developed by Meretoja et al. are potentially helpful tools with which to predict which patients may be at risk for excessive postoperative pain regardless of the pain regimen prescribed.16 These tools could also be helpful to surgeons in identifying patients at higher risk for severe pain so that they may be referred to a pain specialist more quickly or given a nonopioid pain regimen. Further adding to the risks for opioid abuse is that breast reconstruction is often not a “one-and-done” phenomenon. Women often undergo one to four secondary breast reconstruction procedures over the course of a couple of years and receive opioids at each operation. In these patients, the risks for opioid abuse may be compounded as they experience anxiety related to their cancer diagnosis, some mild pain with each procedure, and continually have their life disrupted by postoperative pain.
Our prospective analysis has shown a decrease in pain scores from preoperatively to postoperatively following breast reduction. This is in keeping with previous reports that have found that, following breast reduction, patients experience improved pain and quality-of-life scores.19 , 20 However, there was still a substantial number of leftover tablets at the conclusion of our study. In this series of less than 100 patients, we found that there were a mean of 12.5 tablets left over for each breast reduction patient and a mean of 18.6 tablets left over for each secondary breast reconstruction patient. In total, there were 1551 tablets left over for the entire cohort. With an estimated street value of $5 per pill,21 the value of the leftovers from this study is approximately $7755. As it is likely that the majority of patients are not selling their leftovers, an excess number of opioids at home may offer easy access for other family members/friends with a history of abuse. Perhaps the monetary value of excess opioids following ambulatory surgery is not of major concern. Likely, the chief problem is the risk factor for long-term opioid abuse that has been shown to be associated with prolonged postoperative opioid use.13 , 22 , 23
The major limitation of our study is the small number of patients, which limited our ability to perform multivariate analysis using the previously defined risk factors for increased pain and opioid abuse. This report represents a single surgeon’s experience with potential selection bias. As a result of small sample size, these findings may not be generalizable among the general population. Nevertheless, we believe that this study is an important contribution to the growing literature on pain management. The strengths of this analysis are in the prospective design and well-defined inclusion criteria. In addition, all patients had surgery at the same institution performed by the same senior surgeon, which likely limits any difference in surgical technique that may influence postoperative pain.
Much attention has been paid to the use of opioid-sparing protocols such as the popular enhanced recovery after surgery protocol. Although there are numerous reports using the enhanced recovery after surgery protocol following autologous reconstruction, there has yet to be any study that uses this pathway in an outpatient setting for breast surgery.24–27 The majority of these protocols focus on microsurgical breast procedures and major operations that require inpatient hospital stays. Although these protocols are important, the majority of breast surgery is performed in outpatient centers8; therefore, it is necessary to better understand how to manage pain after breast surgery and treat it effectively. This is the first prospective analysis to assess the use habits and effectiveness of opioids in postoperative pain control following outpatient breast surgery.
Prescribing 30 opioid tablets following ambulatory breast surgery is excessive. The development of opioid-sparing pain regimens for inpatient microsurgical breast reconstruction further emphasizes the need for similar regimens in the outpatient setting. As the most common outpatient surgical procedure performed by plastic surgeons, management of pain after breast surgery is particularly important. It is our responsibility to understand our patients’ risk factors for opioid abuse and inadequate pain management to determine which patients may benefit from more opioids and which patients need less. The cookie-cutter approach to pain management is no longer appropriate.
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©2018American Society of Plastic Surgeons
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