Surgical protocol reduces opioid use for breast reconstruction patients

Breast cancer surgeries can be quite painful, so a team at Houston Methodist West Hospital has worked to develop pain management protocols that help some patients while reducing the use of narcotics.

Dr. Candy Arentz, a breast surgical oncologist, and Dr. Warren Ellsworth, a plastic surgeon, have been using an enhanced recovery after surgery (ERAS) protocol with non-narcotic medications and nerve blocks to lessen pain and the need for narcotics in reconstructive surgeries.

A DIEP flap reconstruction uses tissue and fat from the abdomen and other areas to reconstruct the breast after a lumpectomy or a mastectomy. Ellsworth said the reconstruction can be beneficial because it can look more natural than implants and can last the rest of a patient’s life. But it can be more painful because of the extra incisions. He recognizes that opioid overuse is an issue and said that is just one reason why he and Arentz are working to reduce opioid use.

“We have also, I would say, across the entire house of medicine known about this opioid overuse, opioid dependence and all these challenges that our narcotics impose on our patients, not only the basic side effects of narcotics like nausea, vomiting, constipation, but of course, the dependency,” Ellsworth said.

The ERAS protocol helps patients with pain starting the day before the surgery. “So it prepares their body for the surgery and the pain that could occur, and then we continue the pain control throughout the surgery and then of course postoperatively and have found a significant reduction in the use of narcotics because of this protocol,” Ellsworth said.

As Arentz and Ellsworth were coming up with the protocol, Ellsworth consulted with plastic surgeons at the University of Pennsylvania and Stanford University, modeling the Methodist West protocol after their programs. But according to Ellsworth, Methodist West is the first in the Houston area to make the non-narcotic protocols a priority with their patients in the area of DIEP flap reconstructions.

Ellsworth said starting ERAS required bringing in others in the hospital on board, including the head of anesthesiology so that anesthesiologists could administer nerve blocks, or long-lasting numbing injections into patients’ nerves, and the head of the ICU (intensive care unit) because the new protocols were a big change in pain management. Arentz said it required patient buy-in as well.

“It starts with our conversations in clinic and assuring the patients that they will have decreased pain afterwards than probably what they were expecting,” Arentz said, adding that the protocol is done without using IV medications, which is what most people expect when they are going to have surgery.

Arentz and Ellsworth had planned to start using ERAS in February or March, but COVID-19 shifted it back some. So they started in April. Ellsworth said that all his DIEP patients except one or two have used ERAS. As some patients are already using opioids for pain in other parts of their bodies, they are not good candidates for ERAS.

Ellsworth said ERAS has made a huge difference for patients. He said each patient is sent home with five tablets of regular-strength narcotics in case they need them, but most come to their next appointments having not taken any.

Arentz said that for many of the patients, it is important to know that they will not have narcotics laying around their homes after their surgeries for their families to possibly get into.

Ellsworth said they chose the DIEP flap reconstruction because it is a larger surgery in breast reconstruction. He has started using the ERAS protocol in other procedures like tummy tucks and mommy makeovers. Arentz said it could be used for other breast reconstruction surgeries, as well as other cancer or general surgeries that involve the abdomen.

For patient Laine Twining, the DIEP flap reconstruction took eight hours of surgery and three nights of recovering in the hospital. Last December, Twining went to the emergency room with severe abdominal pain. She had emergency surgery the next morning for a ruptured mass. Pathology on the mass revealed some ovarian cancer cells. Twining went through chemotherapy for that. Because of the ovarian cancer diagnosis and her family history, she was at high risk for developing breast cancer. Together with her doctor, she elected to have a mastectomy and then a reconstruction using the ERAS protocol.

“It was never really something I kind of thought twice about. I just thought, ‘Well, sure,’” Twining said. It’s never been important to me, you know, sort of taking painkillers. In fact, it’s probably more important to me to take as little prescription medication as possible.”

Comparing her reconstruction surgery to the abdominal one she had experienced in December, Twining said the two recoveries were “like night and day.” For the reconstruction, she received a nerve block in her abdomen that lasted for 18 hours. She said she did take a limited amount of medications but only experienced some stiffness and soreness, never any pain.

“The fact that I can go through an eight-hour surgery and not experience any pain is unbelievable to me. It’s really a testament to Dr. Arentz and Dr. Ellsworth, their teams and all others involved in the trial,” Twining said.

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