Reducing Opioid Prescribing After Ambulatory Plastic Surgery With an Opioid-Restrictive Pain Protocol.

Abstract

Opioids are often prescribed in excess, or unnecessarily, after ambulatory surgery. Perioperative opioid stewardships should be a priority with an emphasis on multimodal pain control. In this prospective cohort study, prescribing patterns after implementation of an opioid-restrictive pain protocol, Plastic Surgery Initiative to provide Controlled Analgesia and Safe Surgical Outcomes (PICASSO), were compared with historical controls in an academic plastic surgery department. The protocol was initiated on July 1, 2018, and applied to all adult patients undergoing outpatient plastic surgery. Plastic Surgery Initiative to provide Controlled Analgesia and Safe Surgical Outcomes provides an algorithm for analgesic prescribing based on type of surgery and patient factors. A hospital-based pharmaceutical database was used to identify prescriptions, and univariate analyses were used to compare cohorts. The preprotocol and postprotocol cohorts consisted of 539 and 632 patients, respectively. There was no difference in age (48.2 years vs 48.3 years) or sex (72.2% vs 67.8% female). The proportion of patients filling opioid prescriptions went down from 95% to 76% after PICASSO. The total oral morphine equivalent per opioid prescription (217.5 ± 109.5 vs 87.2 ± 43.4) was significantly less in the PICASSO cohort. Additionally, the proportion of patients receiving nonopioid prescriptions, acetaminophen (60.7% vs 86.9%), ibuprofen (8.7% vs 74.2%), and gabapentin (23.6% vs 57.9%), increased significantly. Opioid refill rates were not increased after implementation (9.1% vs 7.3%, P = 0.35). The PICASSO pain protocol resulted in a 20% decrease in opioid prescriptions and a 2.5-fold decrease in the oral morphine equivalent per prescription, equivalent to eighteen 5-mg oxycodone pills. This opioid-restrictive protocol can improve the analgesic prescribing culture in a plastic surgery department.