Opioid use disorder is an epidemic. In the United States, more than 11 million people abused prescription opioids in 2016. It has been estimated that 42% to 71% of opioids prescribed for pain after surgery are not used. These leftover opioids are at risk of community distribution. Excess prescribing of postoperative opioids has contributed to the opioid epidemic and the current crisis. Several surgical specialties have developed prescribing guidelines to decrease the use of excess prescription opioids. There are few guidelines, however, available for gynecologic procedures for benign indications, especially hysterectomy. More opioids are prescribed for the average patient even when recommended guidelines are used. Moreover, treatment plans are not personalized according to patient preference or prior experience with opioids. When both patients and physicians share information, express treatment preferences, and agree on a treatment plan, the process is called shared decision making (SDM). Tools that are designed to support this process are decision aids. Recently, the positive effect of these tools has been demonstrated in obstetrics and gynecology for opioid prescribing after cesarean delivery. Shared decision making may have a positive influence in decreasing the postsurgical use of prescribed opioids. A crucial aspect of improving patient outcomes through enhanced recovery after surgery protocols is adequate management of postoperative pain without contributing to the epidemic of opioid use disorder. To address the excess use of opioids after surgery, development of evidence-based guidelines has effectively decreased excess opioid prescribing in this clinical scenario. In a pilot study, the use of a decision aid after cesarean delivery was associated with an approximately 50% decrease in opioid prescribing; this reduction when modified to the department-wide level was sustained at a 35% decrease. The primary aimof this prospective quality initiative study was to determine whether SDMreduced opioid prescribing after hysterectomy as compared with before decision aid implementation. A patient decision aid was developed that can be implemented in the preoperative holding area in the outpatient setting. The study was conducted between March 1, 2018, and July 31, 2018, at an academic institution. All participants were undergoing hysterectomy for benign, nonobstetric indications (post-decision aid cohort). Postoperative opioid prescribing patterns before and after the implementation of the decision aid were compared among retrospectively identified patientswho underwent hysterectomy for benign, nonobstetric indication between July 1, 2017, and February 28, 2018 (pre-decision aid cohort). Using a visual decision aid, patients received uniform education regarding postoperative pain management and were then educated regarding the department's guidelines on the maximum number of tablets recommended per prescription and the mean number of opioid tablets used for a similar cohort of patients in a previous study published at the authors' institution. Patients chose the number of opioid tablets they desired to receive on discharge. Patients in the post-decision aid cohort were contacted for structured telephone interviews 14 days after surgery. The primary study outcome was total opioids prescribed before and after implementation of the decision aid. Secondary outcomes included total opioid consumption, satisfaction of patients, and refill requests after intervention implementation.
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