Key Takeaways
- Previous small studies showed that opioids may not be needed for minimally invasive gynecologic surgeries.
- A randomized trial showed that managing pain with non-opioid options was just as effective as routine pain management with opioids after minimally invasive hysterectomy.
- Both study arms reported high satisfaction with their pain management.
Managing pain with non-opioid options was just as effective as routine pain management with opioids after minimally invasive hysterectomy, a randomized trial showed.
Mean pain scores measured using the 11-point Numeric Rating Scale (NRS-11) were 4.0 and 2.1 on postoperative days 1 and 7 for patients taking non-opioids versus 5.0 and 3.1 for those taking opioids, which met the criteria for noninferiority, reported Mostafa Borahay, MD, PhD, of Johns Hopkins University in Baltimore, and colleagues.
Importantly, patients in both groups had high satisfaction with their pain control, with 91% of the non-opioid group and 90% of the opioid group reporting satisfaction on postoperative day 1, and 100% of both groups being satisfied on day 7, they wrote in Obstetrics & Gynecology.
"While additional studies may be needed, it seems that universal prescription of opioids after laparoscopic and robotic hysterectomy may not be needed," Borahay told MedPage Today. "Instead, we can focus on multimodal pain control after surgery and more individualized opioid prescription."
Overprescription of postoperative opioids contributes to excessive consumption, the authors noted, which is particularly relevant in the context of the opioid epidemic.
"With more than 330,000 minimally invasive hysterectomies performed annually in the United States and up to 6.8% of patients at risk of persistent opioid use after hysterectomy, the long-term risks of routine opioid prescriptions merit careful consideration," Borahay and team wrote.
Previous small studies showed that opioids may not be needed for minimally invasive gynecologic surgeries.
"I believe the practice of postoperative opioid prescription is a carryover from the era of open surgery that needs robust assessment," Borahay said.
This noninferiority trial included English-speaking adults undergoing laparoscopic or robotic hysterectomy with or without salpingectomy or oophorectomy for benign indications at an academic medical center from January 2023 to January 2024. The primary indication for surgery was abnormal uterine bleeding and leiomyomas.
Overall, 64 participants were included in the final analysis, with 33 in the opioid group and 31 in the non-opioid group. Mean age was 43, 48-52% were Black, and 44-45% were white.
Those with chronic pain syndromes, current or long-term opioid use, and allergies and contraindications to the study medications were excluded, as were those undergoing concurrent procedures.
All patients received 1,000 mg of acetaminophen before surgery and were randomized 1:1 to non-opioids or opioids on the day of surgery. The non-opioid arm received postoperative prescriptions for acetaminophen 500 mg (30 tablets) and ibuprofen 600 mg (30 tablets). The opioid arm received the same acetaminophen and ibuprofen prescriptions in addition to 12 tablets of 5-mg oxycodone. Patients in the non-opioid arm could request opioids if their pain was not adequately managed by ibuprofen and acetaminophen.
Patients were instructed to take a non-opioid medication every 6 hours for the first 72 hours postoperatively, then as needed. Acetaminophen and ibuprofen consumption didn't differ significantly between study arms.
Eight patients in the non-opioid group requested an opioid prescription, and none requested a second prescription. Three participants in the opioid group requested a second prescription. By day 7, median postoperative oxycodone consumption was one tablet in the opioid group and zero in the non-opioid arm.
While some patients in the non-opioid group requested opioids, they did not demonstrate improved pain scores when compared with the opioid group, which raised the question of "whether oxycodone effectively addresses the predominant pain types experienced after minimally invasive hysterectomy," Borahay and colleagues noted.
They pointed to a few study limitations, including that pain management in the post-anesthesia care unit was not standardized, that opioid consumption was self-reported, and the study was not blinded. In addition, patients with chronic pain, a known predictor of postoperative opioid use, were excluded, which may have contributed to underestimation of total consumption.