Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Master of Science




Van Koughnett, Julie Ann

2nd Supervisor

Leslie, Ken

3rd Supervisor

Brackstone, Muriel


Surgeons play a significant role in the opioid crisis. A standardized, multipronged analgesia protocol was implemented with the objective of providing adequate analgesia while reducing opioids after outpatient breast and anorectal surgery.

A prospective, pre- and post-intervention study was designed to demonstrate non-inferiority for patient-reported post-operative pain. The intervention included patient and provider education, and multimodal perioperative analgesic strategies including opioid rescue prescriptions.

We evaluated 266 procedures. After implementation of the STOP Narcotics protocol, average post-operative pain scores in the post-intervention groups was non-inferior compared to the pre-intervention groups [(2.0 vs 2.1/10, p = 0.40, breast procedures) and (2.8 vs 2.6/10, p = 0.33, anorectal procedures)]. Opioid prescribing decreased by 50%. Only 45% of patients filled their rescue opioid prescriptions.

A standardized pain care bundle significantly decreased opioid prescribing while adequately treating post-operative pain. This initiative provides a framework for future guidelines in outpatient breast and anorectal surgery.

Summary for Lay Audience

Opioid overdoses have become one of the leading causes of preventable deaths in North America. Surgeons play a major role for many reasons. First, prescription opioids are still a major source of opioid misuse. Second, the risk of chronic opioid use after surgery is 5-15%. Finally, diversion of excess, unused prescriptions is a major contributor to opioid misuse.

The impact of implementing a new standardized pain care bundle, termed “The STandardization of Outpatient Procedure Narcotics (STOP Narcotics)”, was assessed with the objective of adequately controlling patient pain while reducing post-operative opioids after breast and anorectal outpatient surgery.

The multi-pronged intervention consisted of 4 main components: Patient Education was directed towards clarifying pain expectations, and coupled with written instructions for optimal utilization of medications for pain control; Provider Education focused on understanding the recommended multi-modal analgesic strategies; Intra-Operative Pain Management Strategy included medications targeting pain control and nausea were given by the anesthesiologist; and, Post-Operative Pain Management Strategy, where prescription for an anti-inflammatory was given, along with instructions for regular acetaminophen use. A separate optional prescription for a reduced amount of an opioid was also given.

Through clarifying patient expectations and providing clear instructions on how to use non-opioid medications effectively for pain, equivalent post-operative pain control was achieved, along with increased patient satisfaction in the post-intervention group. By using multiple non-opioid medications there was a 50% reduction in opioid prescribing. More significantly, only 45% of patients filled their opioid prescription. There was no significant difference in prescription refills, and appropriate medication disposal of excess medication increased after the intervention was implemented.

If this intervention was implemented province-wide (over 20,000 breast procedures are performed in Ontario each year) and opioid prescriptions decreased from 30 pills to 10 pills with only 45% of patients filling their prescription, this would result in a decrease of pills consumed from 600,000 pills to 90,000 pills for breast surgery patients alone. Similar standardized interventions may be implemented at other institutions and expanded to other more complex procedures and surgical disciplines, and may provide a foundation for future guidelines and impact the opioid epidemic in a truly meaningful way.

JACS article.pdf (343 kB)
This is appendix 5.5. The whole article should be included in the thesis. It is previously published work.

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