Nonpharmacologic Pain Intervention Reduces Opioid Use Following Minimally Invasive Gynecologic and Urologic Surgery

Article

The implementation of a nonpharmacologic pain intervention bundle helped decrease opioid use among patients recovering from gynecologic and urologic surgeries at a comprehensive cancer center.

Leigh McGrath Ehinger, DNP, AGPCNP-BC

Leigh McGrath Ehinger, DNP, AGPCNP-BC

Nonpharmacologic interventions such as acupressure, touch therapy, and mindful breathing meditation decreased opioid use in patients recovering from minimally invasive gynecologic and urologic surgery, according to findings published in the Clinical Journal of Oncology Nursing. These strategies did not negatively affect pain scores or length of stay, suggesting their utility in this setting, according to nurse investigators.

Preintervention (n = 96), the median dosage of morphine per patients was 4 mg (IQR, 8). The median pain score reported by patients when they were admitted on the floor was 4 (IQR, 8), and the median pain score at time of discharge was 3 (IQR, 3). The median number of documented nonpharmacologic interventions per patient was 3 (IQR, 6).

Postintervention (n = 86), the median dosage of morphine per patients was 0 mg (IQR, 5). The median pain score reported by patients on the floor was 3 (IQR, 4), and the median pain score at discharge was 3 (IQR, 4). There were no documented nonpharmacologic interventions (IQR, 2).

“The project’s findings suggest that using a nurse-driven nonpharmacologic pain management intervention bundle is worthwhile in the minimally invasive gynecologic and urologic surgery population,” Leigh McGrath Ehinger, DNP, AGPCNP-BC, nurse practitioner at Memorial Sloan Kettering Cancer Center, and study authors, wrote in the study.

“The evidence-based bundle of nonpharmacologic interventions in the nursing orders significantly increased the documented use of these interventions and significantly decreased postoperation opioid use without negatively affecting pain scores,” they added. “Therefore, orders endorsing the use of nurse-driven complementary therapies for pain are recommended.”

According to study authors, the median number of documented interventions is clinically meaningful because it represents a change in practice. Moreover, they assert that the decrease in postoperation opioid use is promising and gives reason to speculate that patients may be able to continue avoiding opioids postdischarge. Given the current opioid epidemic, increasing these nonpharmacologic interventions and avoiding medications is what many patients and providers, including these study authors, want, they state.

Postoperation pain management typically includes acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, but should also include nonpharmacologic interventions. Nonpharmacologic interventions are noninvasive, associated with minimal to no risk, and preferred patients when possible. The nonpharmacologic pain management strategies used in this study included decreasing lighting and noise, encouraging listening to music via headphones, exercise—as tolerated—for 1 to 2 hours each day, and stretching in bed by bending and straightening legs or rocking knees side to side with legs bent, mint or ginger tea for gas, and hot packs to the abdomens or shoulders as needed. Moreover, interactive videos demonstrated the use of the following interventions for patients: acupressure for pain and headaches, touch therapy for caregivers (massage), guided imagery mediation, and mindful breathing meditation.

The study included patients who were recovering from minimally invasive gynecologic or urologic surgery on the ambulatory extended recovery (AXR) program during the predesignated time frames. This included patients receiving total hysterectomy with or without bilateral salpingectomy-oophorectomy, unilateral or bilateral oophorectomy or ovarian cystectomy with or without salpingectomy, radical prostatectomy, partial or radical nephrectomy, adrenalectomy (robotic assisted only), nephroureterectomy, and gynecologic debulking surgery.

Demographic information and surgical information were deemed to be similar between the pre- and postimplementation groups. In both groups, most patients were classified as American Society of Anesthesiologists category 3. Middle-aged women represented most patients, in both groups, as well.

The median duration of surgery was 2 hours and 50 minutes in both groups. The mean length of time between admission and discharge was 18.6 minutes less postimplementation, though this was not a significant change (P = .663).

Moreover, following the intervention, the number of documented nonpharmacologic pain management interventions were increased, though this was deemed nonsignificant. The median number of pharmacologic pain interventions increased by 3 per patient, and the median number of opioids postoperation decreased from 4 to 0 mg of morphine equivalents (P = .01).

Pain scores, which were evaluated using a numeric scale of 0 to 10, were documented at the time of the first follow-up nursing assessment on the AXR unit. Following the implementation, these scores significantly decreased, with a median difference of 1 (P = .039), although there was no difference in pain scores at the time of discharge (P = .0321). One of the goals of the study authors who designed this study was to reduce the number of patients who require inpatient admission for pain control following their abdominal laparoscopic procedures by 30%. However, this was not achieved.

They also noted that the reduction in length of stay was not significant (20.89 vs 20.58 hours) it is meaningful because it suggest that nonpharmacologic pain management does not take significantly longer to decline, compared with analgesia alone, and does not delay recovery time.

Study authors acknowledged that no postdischarge outcomes were measured and that it is unclear whether patients continued to have good pain control at home. Additionally, the data were analyzed as 1 group, and does not separate surgery types or other potential variables that may be of interested.

“Additional research is needed on the specific nonpharmacologic interventions in this population and whether these results are transferable to all patients undergoing abdominal laparoscopic surgery,” they concluded.

Reference

Ehinger L, Marte MK, Kozachik SL. Nonpharmacologic pain management for patients in ambulatory extended recovery after minimally invasive gynecologic and urologic surgery. Clin J Oncol Nurse. 2023;50(1):47-57. doi:10.1188/23.ONF.47-57

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