Eliminating Narcotic Prescriptions from Outpatient Minimally Invasive Gynecologic Surgery

Narcotic prescribing patterns vary greatly among gynecologists performing minimally invasive gynecologic surgery (MIGS). There is no clear consensus or established guideline regarding the choice of narcotic or total amount to be prescribed, if any, for MIGS. These represent a generally well-tolerated group of procedures that are less painful than conventional open surgery. Unnecessary opioid prescriptions and excess unused narcotics have been identified as major contributors to narcotic abuse in the community, and efforts geared towards minimizing unnecessary narcotic prescriptions may help curb the growing opioid crisis.

This study suggests eliminating opioids from discharge prescriptions following outpatient MIGS in select patients. Given the general tolerability and low pain associated with MIGS, the investigators hypothesize that elimination of narcotics from post-operative pain control, in conjunction with regular use of non-narcotic analgesics, will result in analgesia and early recovery that is no worse than a standard narcotic-containing discharge prescription.

Women undergoing elective outpatient laparoscopic gynecologic surgery at two medical center associated with the McGill University Health Centre will be recruited and screened for exclusion criteria. Patients will be randomly allocated to either intervention or control groups in a one to one fashion. Patients in both intervention and control group will undergo surgery under a standardized anesthesia protocol. Important surgical steps that can affect post-operative pain will be standardised and recorded with a surgical checklist to reduce inter-surgeon variability. Patient allocated to the intervention arm will then be discharged home with a prescription for regular acetaminophen and naproxen for 48 hours, and then as needed for one week's duration. Patient in control group will be discharge with a standard prescription of five tabs of 1 mg hydromorphone, with regular non-opioid analgesic use.

All patient will be contacted on day one and seven after surgery to evaluate pain scores, mobility, adequacy of analgesia, adherence to treatment, side-effects, and total opioid consumption.

Inclusion criteria

• Women undergoing elective outpatient gynecologic laparoscopy
• Able to provide informed consent
• Planned for same day discharge

Exclusion criteria

• Chronic pain conditions including, but not limited to: chronic pelvic pain, fibromyalgia, connective tissue disorders, migraines on medication, severe osteoarthritis, sciatica, degenerative disk disease
• Regular use of analgesia or narcotics. Defined as use of pain medication on most days of the week, most weeks of the month
• History of substance abuse (opioid addiction, IV drug use, etc.)
• Known depression or anxiety conditions with or without medication
• Eastern Cooperative Oncology Group (ECOG) performance status 3 or greater
• Current or recent use of pain modulators such as pregabalin or gabapentin (one month pre-operatively).
• Allergy or contraindication to acetaminophen or NSAIDs or hydromorphone/narcotics
• Intraoperative complications :
• Conversion to laparotomy or mini-laparotomy > 4 cm
• Intra-operative gastrointestinal or urologic injury
• Intra-operative hemorrhage or need for blood transfusion
• Need for admission