Annals of Surgical Oncology

, Volume 26, Issue 10, pp 3295–3304 | Cite as

The Standardization of Outpatient Procedure (STOP) Narcotics: A Prospective Health Systems Intervention to Reduce Opioid Use in Ambulatory Breast Surgery

  • Luke B. Hartford
  • Julie Ann M. Van Koughnett
  • Patrick B. Murphy
  • Sarah A. Knowles
  • Robin B. Wigen
  • Laura J. Allen
  • Collin F. M. Clarke
  • Muriel Brackstone
  • Daryl K. Gray
  • Allison H. MaciverEmail author
Breast Oncology



During the past 15 years, opioid-related overdose death rates for women have increased 471%. Many surgeons provide opioid prescriptions well in excess of what patients actually use. This study assessed a health systems intervention to control pain adequately while reducing opioid prescriptions in ambulatory breast surgery.


This prospective non-inferiority study included women 18–75 years of age undergoing elective ambulatory general surgical breast procedures. Pre- and postintervention groups were compared, separated by implementation of a multi-pronged, opioid-sparing strategy consisting of patient education, health care provider education and perioperative multimodal analgesic strategies. The primary outcome was average pain during the first 7 postoperative days on a numeric rating scale of 0–10. The secondary outcomes included medication use and prescription renewals.


The average pain during the first 7 postoperative days was non-inferior in the postintervention group despite a significant decrease in median oral morphine equivalents (OMEs) prescribed (2.0/10 [100 OMEs] pre-intervention vs 2.1/10 [50 OMEs] post-intervention; p = 0.40 [p < 0.001]). Only 39 (44%) of the 88 patients in the post-intervention group filled their rescue opioid prescription, and 8 (9%) of the 88 patients reported needing an opioid for additional pain not controlled with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) postoperatively. Prescription renewals did not change.


A standardized pain care bundle was effective in minimizing and even eliminating opioid use after elective ambulatory breast surgery while adequately controlling postoperative pain. The Standardization of Outpatient Procedure Narcotics (STOP Narcotics) initiative decreases unnecessary and unused opioid medication and may decrease risk of persistent opioid use. This initiative provides a framework for future analgesia guidelines in ambulatory breast surgery.



We acknowledge Samuel Gray, BSc, and Carlos Garcia-Ochoa, MD, who were involved in data collection for this study. We also acknowledge Dr. Ken Leslie MD, MHPE, FRCSC, who was instrumental in the study design as well as ongoing feedback and input throughout the study. Dr. Supriya Singh and the orthopedic surgery team at London Health Sciences Centre also provided study motivation and guidance stemming from their recent randomized control trial involving written instructions and opioid use in orthopedic surgery at our institution.56


There are no conflicts of interest.


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Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Luke B. Hartford
    • 1
  • Julie Ann M. Van Koughnett
    • 1
    • 2
  • Patrick B. Murphy
    • 1
  • Sarah A. Knowles
    • 1
  • Robin B. Wigen
    • 1
  • Laura J. Allen
    • 1
  • Collin F. M. Clarke
    • 3
  • Muriel Brackstone
    • 1
    • 2
  • Daryl K. Gray
    • 1
  • Allison H. Maciver
    • 1
    • 2
    Email author
  1. 1.Division of General Surgery, Department of Surgery, Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  2. 2.Division of Surgical Oncology, Department of Oncology, Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  3. 3.Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and DentistryWestern UniversityLondonCanada

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