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Importance: Opioids are routinely prescribed for postoperative home pain management for most patients in the United States, with limited evidence of the amount needed to be dispensed. Opioid-based treatment often adversely affects recovery. Prescribed opioids increase the risk of chronic opioid use, abuse, and diversion and contribute to the current opioid epidemic., Objective: To evaluate whether after hospital discharge, postsurgical acute pain can be effectively managed with a markedly reduced number of opioid doses., Design, Setting, and Participants: In this case-control cohort study, an ultrarestrictive opioid prescription protocol (UROPP) was designed and implemented from June 26, 2017, through June 30, 2018, at a single tertiary-care comprehensive cancer center. All patients undergoing gynecologic oncology surgery were included. Patients undergoing ambulatory or minimally invasive surgery (laparoscopic or robotic approach) were not prescribed opioids at discharge unless they required more than 5 doses of oral or intravenous opioids while in the hospital. Patients who underwent a laparotomy were provided a 3-day opioid pain medication supply at discharge., Main Outcomes and Measures: Total number of opioid pain medications prescribed in the 60-day perioperative period, requests for opioid prescription refills, and postoperative pain scores and complications were evaluated. Factors associated with increased postoperative pain, preoperative and postoperative pain scores, inpatient status, prior opioid use, and all opioid prescriptions within the 60-day perioperative window were monitored among the case patients and compared with those from consecutive control patients treated at the center in the 12 months before the UROPP was implemented., Results: Patient demographics and procedure characteristics were not statistically different between the 2 cohorts of women (605 cases: mean [SD] age, 56.3 [14.5] years; 626 controls: mean [SD] age, 55.5 [13.9] years). The mean (SD) number of opioid tablets given at discharge after a laparotomy was 43.6 (17.0) before implementation of the UROPP and 12.1 (8.9) after implementation (P < .001). For patients who underwent laparoscopic or robotic surgery, the mean (SD) number of opioid tablets given at discharge was 38.4 (17.4) before implementation of the UROPP and 1.3 (3.7) after implementation (P < .001). After ambulatory surgery, the mean (SD) number of opioid tablets given at discharge was 13.9 (16.6) before implementation of the UROPP and 0.2 (2.1) after implementation (P < .001). The mean (SD) perioperative oral morphine equivalent dose was reduced to 64.3 (207.2) mg from 339.4 (674.4) mg the year prior for all opioid-naive patients (P < .001). The significant reduction in the number of dispensed opioids was not associated with an increase the number of refill requests (104 patients [16.6%] in the pre-UROPP group vs 100 patients [16.5%] in the post-UROPP group; P = .99), the mean (SD) postoperative visit pain scores (1.1 [2.2] for the post-UROPP group vs 1.4 [2.3] for pre-UROPP group; P = .06), or the number of complications (29 cases [4.8%] in the post-UROPP group vs 42 cases [6.7%] in the pre-UROPP group; P = .15)., Conclusions and Relevance: Implementation of a UROPP was associated with a significant decrease in the overall amount of opioids prescribed to patients after gynecologic and abdominal surgery at the time of discharge for all patients, and for the entire perioperative time for opioid-naive patients without changes in pain scores, complications, or medication refill requests.

Opioid misuse is a public health emergency in the United States with substantial burden in morbidity and economic costs. Surgery is a known risk factor for chronic opioid use, still health care providers are often resistant to change opioid prescribing patterns due to concern for adequate postsurgical recovery and decreased patient satisfaction. In order to minimize the risk of chronic opioid use, we developed and successfully implemented restrictive opioid prescribing protocols across all surgical services at a large tertiary cancer center. We measured patient reported outcomes to evaluate whether patient satisfaction with postsurgical pain management during recovery is influenced by the amount of opioid pain medications provided in the postoperative period after hospital discharge. In this case-control cohort study, restrictive opioid prescription protocols were designed and implemented from February 1st, 2019 across all surgical services at a single tertiary-care comprehensive cancer center. In general, all patients undergoing ambulatory or minimally invasive surgery were not prescribed opioids, while patients undergoing a major open surgical procedure were provided no more than a 3-day opioid pain medication supply at the time of discharge. All outgoing prescriptions and refills were strictly monitored on a daily base and tracked and verified by the New York State Prescription Monitoring Program Registry (I-STOP) for the 30-day postoperative period an all surgical patients. Validated Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were randomly implemented during postoperative visits to survey surgical patients on all surgical services 6 months prior to (08/2018-01/2019) and for 6 months after (02/2019-08/2019) the ROPPs implementation. A total of 698 patients were randomly surveyed during the study period, with 338 patients in the pre-implementation cohort and 360 patients who had surgery after the ROPP was implemented and received little to no opioids following discharge. The compliance with the protocol across surgical services was 95% and the number of opioid pain medications prescribed to all surgical patients in the first 30 days of postoperative recovery was significantly decreased (p<0.01). After adjusting for age, gender, body mass index (BMI), and surgical complexity, patient reported outcome measures demonstrated no difference in patient satisfaction with postoperative pain relief (p=0.66) regardless of the amount of opioid prescribed. There was no difference in pain intensity within the first 2 weeks after hospital discharge (p=0.20), and the postsurgical pain did not interfere with day-to-day activities (p=0.30). Patients managed on the ROPP reported using more non-steroidal anti-inflammatory drugs (p=0.01) in the recovery period. Our study demonstrates that implementation of restrictive opioid prescription protocols across surgical services is feasible and led to significant decrease in opioid pain medication use in the postoperative period, without compromising patient satisfaction or interfering with patient active recovery and day-day to activities after hospital discharge. [ABSTRACT FROM AUTHOR]