The Impact of Education and Prescribing Guidelines on Opioid Prescribing for Breast and Melanoma Procedures

Abstract

Background: Excessive opioid prescribing is common in surgical oncology, with 72% of prescribed opioids going unused after curative-intent surgery. In this study, we sought to reduce opioid prescribing after breast and melanoma procedures by designing and implementing an intervention focused on education and prescribing guidelines, and then evaluating the impact of this intervention.

Methods: In this single-institution study, we designed and implemented an intervention targeting key factors identified in qualitative interviews. This included mandatory education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. After the intervention, interrupted time-series analysis was used to compare the mean quantity of opioid prescribed before and after the intervention (July 2016-September 2017). We also evaluated the frequency of opioid prescription refills.

Results: During the study, 847 patients underwent breast or melanoma procedures and received an opioid prescription. For mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention (p = 0.03), equivalent to 13 tablets of oxycodone 5 mg. For lumpectomy or breast biopsy, the mean quantity of opioid prescribed decreased by 42%, or 12 tablets of oxycodone 5 mg (p = 0.07). Furthermore, opioid prescription refills did not significantly change for mastectomy/wide local excision (13% vs. 14%, p = 0.8), or lumpectomy/breast biopsy (4% vs. 5%, p = 0.7).

Conclusion: Education and prescribing guidelines reduced opioid prescribing for breast and melanoma procedures without increasing the need for refills. This suggests further reductions in opioid prescribing may be possible, and provides rationale for implementing similar interventions for other procedures and practice settings.

Figure 1:. Intervention for opioid prescribing.

The intervention was designed based on previous qualitative work, which identified education and prescribing guidelines as interventions likely to change opioid prescribing behavior in surgical oncology. The intervention had three components: 1) mandatory education for prescribers including educational conferences and written protocols; 2) evidence-based prescribing guidelines specific to each procedure based on previously published studies and patient-reported opioid consumption data from our institution; and 3) standardized patient instructions emphasizing using non-opioid analgesics first with opioids only for breakthrough pain, safe storage of opioids, and safe disposal of unused opioids.

Figure 2:. Standardized patient instructions for pain management.

All patients were provided with standardized written instructions for pain management. The instructions were also explained in-person by nursing staff. Key topics reviewed included using nonopioid analgesics first with opioids only for breakthrough pain, safe storage of opioids, and safe disposal of unused opioids.

Figure 3:. Impact of the intervention on quantity of opioid prescribed.

Interrupted time series analysis was used to evaluate the impact of the intervention on the mean quantity of opioid prescribed each month. Error bars show 95% confidence intervals for each mean. [A] For simple mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention, equivalent to 13 tablets of 5 mg oxycodone (P = 0.03). [B] For lumpectomy or breast biopsy, the mean quantity of opioid prescribed immediately decreased by 42% after the intervention, equivalent to 12 tablets of 5 mg oxycodone (P = 0.07).

Figure 4:. Quantity of opioid prescribed and opioid prescription refills.

Study outcomes were compared during the pre-intervention period (four months before the intervention), transition period (seven months after the intervention), and postintervention period (four months after the transition period). [A] Errors bars show 95% confidence intervals for each mean. The mean quantity of opioid prescribed during the post-intervention period was significantly reduced compared to the pre-intervention period for simple mastectomy or wide local excision for melanoma (30 vs. 16 tablets of 5 mg oxycodone, P < 0.001) and lumpectomy or breast biopsy (24 vs. 10 tablets of 5 mg oxycodone, P < 0.001). [B] Opioid prescription refills during the post-intervention period were not significantly different compared to the pre-intervention period for simple mastectomy or wide local excision for melanoma (13% vs. 14%, P = 0.8) and lumpectomy or breast biopsy (4% vs. 5%, P = 0.7).