A comprehensive model for pain management in patients undergoing pelvic reconstructive surgery: A prospective clinical practice study.

BACKGROUND: Postoperative opioid prescription patterns play a crucial role in driving the opioid epidemic. A comprehensive system towards pain management for surgical patients is necessary to minimize overall opioid consumption.

OBJECTIVE: To evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring post discharge narcotic use in morphine equivalents (milligrams of morphine, MME).

METHODS: This is a prospective clinical practice study that included women undergoing inpatient female pelvic reconstructive surgery from December 2018 to June 2019, with overnight stay after surgery. As a routine protocol, all patients followed an enhanced recovery after surgery (ERAS) protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory (BPI) surveys were collected preoperatively and at postoperative day 1 (POD1). BPI and activities assessment scale (AAS) scores were collected at postoperative week 1 (POW1) and again 4-6 weeks (POW4-6) after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription of controlled substances (EPCS) software platform, which is mandated in the state of Connecticut (CT) for all controlled substances prescriptions and refills. Patients were called at POW1 and POW4-6 to answer questions regarding their pain, the number of narcotic tablets remaining and patient satisfaction regarding pain management. Patient electronic medical records and the CT Prescription Monitoring and Reporting System were reviewed to determine if patients received narcotic refills. Primary outcome was post discharge narcotic use measured in MME. Secondary outcomes evaluated refill rate, BPI and AAS scores and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range (IQR). Bivariate comparisons used Spearman's rho (ρ) with α=0.05.

RESULTS: 113 patients were enrolled; the median (IQR) MME prescribed (including refills) was 112.5 (112.5-112.5). The median (IQR) PDNU was 24.0 (0-82.5) MME, which is equivalent to fewer than four oxycodone (5mg) tablets. 75% of our participants required fewer than 11 oxycodone tablets. The median unused MME was 90.0 (45-112.5). 81.4% (92/113) and 83.2% (94/113) of patients at POW1 and POW4-6, respectively, reported being satisfied or extremely satisfied with their post discharge pain control. 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the POW1 and POW4-6 time points. At POW4-6, 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 PDNU (ρ=0.065, p=0.495). Patients reported median BPI scores for "average pain" of 0 (no pain) at POW1 and POW4-6; however, scores did not clinically correlate with PDNU. AAS scores were not correlated with PDNU.

CONCLUSIONS: Majority of patients after pelvic reconstructive surgery use fewer than 11 oxycodone (5mg) tablets, averaging less than four 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 since 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 while maximizing patient satisfaction.