Gynecologic Surgery Postoperative Narcotic Use Emily Buttigieg MD

Gynecologic Surgery Postoperative Narcotic Use Emily Buttigieg, MD, University of Wisconsin-Madison (ebuttigieg@uwhealth. org) Heidi Brown, MD, University of Wisconsin-Madison Cassidy Tierney, MD, University of Wisconsin-Madison Maria Villalon Landeros, BS, University of Wisconsin-Madison

Background ● In October 2017, the US Department of Health and Human Services declared the opioid crisis a nationwide public health emergency ● In 2018, 70% of drug overdose deaths involved an opiate ○ Deaths from prescription opiates were 4 X higher than in 1999 ● 80% of heroin users first misused prescription opioids

Objectives 1. Examine opioid prescribing patterns after gynecology procedures at one large academic institution 2. Estimate an ideal number of pills to prescribe in order to align prescription practices to patients needs 3. Reduce the overall number of unused opiates in the community

Study Design ● Quality Improvement project ● Collect data on current prescribing habits for all gynecological surgeries in real-time ○ Insert project information into the discharge paperwork for patient awareness ○ Collect patient and prescription data from the Electronic Medical Record ○ Message patients at 7 days to assess for use and satisfaction

Study Participants Surgery: 840 Surveys Sent ○ ○ ○ ○ 172 Participants Responded Laparoscopic Hysterectomy - 22 (1 robotic) Vaginal Hysterectomy - 14 (7 with no repairs) Abdominal Hysterectomy - 5 Laparoscopy - 38 Hysteroscopy - 44 (3 - diagnostic) Suction D&C/D&E - 14/5 Vaginal Repairs - 13 (3 with intraperitoneal entry) Vulvar - 5 Cervical - 5 Interstim - 4 Cystoscopy with botox - 1 Endometrial biopsy - 1 Not gynecologic - 1 Surgery Subtypes Used: Hysterectomy: -Laparoscopic: 22 -Vaginal: 14 Laparoscopy: 38 Vaginal Repairs: 13 Operative Hysteroscopy: 41 Suction D&C: 14

Hysterectomy Laparoscopic/Robotic (22 with 1 robotic): ● Prescribed: 160 MME (Range 75 -300) ● Used: ○ 93 MME (Range 0 -300) ○ 80%ile: 156 MME ● 18% (4) Patients required narcotic refill ● 81% Satisfied with pain control Vaginal (14 with 7 involving additional vaginal surgery): ● Prescribed: 205 MME (Range 37. 5 -450) ● Used: ○ 66 MME (Range 0 -300) ○ 80%ile 120 MME ● 21% (3) Patients required narcotic refill ● 78% Satisfied with pain control

Non-Hysterectomy Laparoscopy (38): ● Prescribed: 112 MME (Range 0 -337. 5) ● Used: ○ 51 MME (Range 0 -165) ○ 80%ile: 109. 5 MME ● 13% (5) Patients required narcotic refill ● 89% Satisfied with pain control Vaginal Repairs (13 with 3 involving intraperitoneal entry): ● Prescribed: 76 MME (Range 0 -225) ● Used: ○ 8 MME (Range 0 -60) ○ 80%ile: 12 MME ● 0 Patients required narcotic refill ● 100% Satisfied with pain control

Non-Hysterectomy Operative Hysteroscopy (41): ● Prescribed: 1. 3 MME (Range 0 -7. 5) ● Used: ○ 0. 8 MME (Range 0 -30) ○ 80%ile: 0 MME ● 0 Patients required narcotic refill ● 95% Satisfied with pain control Suction D&C (14): ● Prescribed: 1. 1 MME (Range 0 -7. 5) ● Used: ○ 0. 5 MME (Range 0 -7. 5) ○ 80%ile: 0 MME ● 0 Patients required narcotic refill ● 87% Satisfied with pain control

Endometriosis Subanalysis Laparoscopic Hysterectomy: Laparoscopy - No Hysterectomy Endometriosis (9): ● Prescribed: 167 MME (Range 75 -300) ● Used: ○ 97 MME (Range 0 -300) ○ 80%ile 141 MME Endometriosis (18): ● Prescribed: 115 MME (Range 40 -300) ● Used: ○ 52 MME (Range 0 -165) ○ 80%ile 109. 5 MME No Endometriosis (12): ● Prescribed: 155 MME (Range 90 -262. 5) ● Used: ○ 90 MME (Range 0 -240) ○ 80%ile 175. 5 MME No Endometriosis (20): ● Prescribed: 113 MME (Range 40 -337. 5) ● Used: ○ 51 MME (Range 0 -144) ○ 80%ile 106. 5 MME Overall no statistically significant difference in narcotic prescriptions or use between patients with and without endometriosis

Conclusion Following benign gynecologic surgery, most patients consume fewer opioids then are prescribed • Overall patients were satisfied with their pain control postoperatively • There is no statistically significant different in narcotic prescription or use between patients with and without endometriosis undergoing gynecologic surgeries •

Limitations • Single Institution • Lower response rate

Future Directions ● Calculate the number of narcotics needed to meet the needs of 80% of surveyed patients, stratified by surgical approach ● Distribute findings and recommendations to providers ● Repeat study with a similar design of patient surveys postoperatively ● Assess narcotic prescription numbers, patient use, and overall patient satisfaction following this educational intervention

Acknowledgements Primary Investigator: Heidi Brown, MD (University of Wisconsin-Madison) Research Assistants: Cassidy Tierney, MD (University of Wisconsin-Madison) and Maria Villalon Landeros, BS, (University of Wisconsin-Madison)