Surgeons routinely prescribe opioids to breast cancer patients undergoing lumpectomy, but most patients, including those whose surgery also involves sentinel lymph node biopsy, can control pain with nonnarcotic medication, according to new research.

In 2018, Memorial Sloan Kettering Cancer Center (MSKCC) eliminated routine opioid prescriptions for patients undergoing lumpectomy with no axillary procedure, replacing the narcotic medications with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.

“As only 1% of our patients required an opioid for pain control with this regimen, we hypothesized that patients having lumpectomy with sentinel lymph node [SLN] biopsy could also be routinely discharged without opioids with a low failure rate,” said Tracy-Ann Moo, MD, a breast surgical oncologist at MSKCC in New York City.

To test their hypothesis, Dr. Moo and her colleagues studied 663 patients over a six-month period. In the first three months, most patients (92%) were discharged with prescriptions for opioid medications. In the following three-month period, patients were sent home with NSAIDs and instructions to use acetaminophen as needed; only 14% of patients were prescribed opioid medications, mostly due to a contraindication to NSAIDs.

In a post-discharge survey, patients reported daily pain on a scale of 0 to 10 for five days after surgery, and on day 5 reported the number of opioids or nonnarcotic medications they had taken to that point.

During the opioid prescribing period, 61% of patients reported taking no pills; among those who used the medications, the median number of pills taken by postoperative day 5 was four. During the nonnarcotic medication period, only five patients sent home with NSAIDs required opioids, for a failure rate of 2%.

“Comparing the maximum reported pain scores of postoperative days 1 to 5 in both study periods, we found no difference between patients treated during the first three months and those treated in the second three months,” Dr. Moo said. “Furthermore, the pain scores were comparable between the two time periods, with most patients reporting 0 or mild pain.”

The shift to prescribing narcotic medications as needed rather than routinely after lumpectomy with SLN biopsy resulted in a plunge of 78% in opioid prescriptions between the two time periods.

“At MSKCC, where surgeons treat approximately 2,500 breast cancer patients annually with these procedures, this translates into 19,500 fewer opioid pills being dispensed annually, a dramatic reduction in the number of pills that could potentially be misused,” Dr. Moo said. She presented her research at the American Society of Breast Surgeons’ Virtual Education Series, held in lieu of the society’s 2020 annual meeting.

Theresa Schwartz, MD, a professor of surgery at Saint Louis University School of Medicine, in St. Louis, stopped prescribing narcotic medications for all patients not undergoing reconstruction after reading the book “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” by Beth Macy (Little, Brown and Co.; 2018), which describes the marketing tactics of the manufacturers of oxycodone and the vulnerability of everyday people to narcotic medications.

“It really doesn’t take much. You don’t have to be on narcotics for an extended period to become addicted. For some people, withdrawal symptoms are felt after only a few days of use,” she said.

In the 18 months since she stopped routinely prescribing narcotics, Dr. Schwartz hasn’t had one patient call with uncontrolled pain. “That’s anecdotal information, and it helps me make appropriate decisions for my patients specifically, but this paper presents real data that demonstrates patients have adequate pain control without the use of narcotic medication.”

But the culture that evolved around narcotics is complicated, and may be difficult to change, Dr. Schwartz said. “Narcotic medications were marketed to the degree that everyone, patients and surgeons, thought they were a necessary piece of any postoperative care package. I routinely talk to my patients about why narcotic medications will not be prescribed after their operation. Up-front education on the topic helps patients understand that we have alternative medication options for pain control and that narcotics simply aren’t necessary.”