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Over a 20-year period, opioid-related deaths in the United States have increased sixfold. In 2017, therefore, the Department of Health and Human Services officially declared this rapid increase in drug-related mortality a public health emergency. During that year, according to the Centers for Disease Control (CDC), more than 70,200 people died from drug overdoses; roughly 47,700 of those deaths involved opioids. Therefore, more people now die of opioid abuse or misuse annually than die of breast cancer. Although this trend is multifactorial, a sharp increase in the number of opioid prescriptions is considered an important—and addressable—cause. Despite the opioid crisis being a government and public health priority, the CDC offers little guidance for managing acute postsurgical pain. Although there are CDC pain management guidelines, they are written for primary care providers and make recommendations only for the treatment of chronic pain. It has, therefore, been up to individual institutions and professional societies to create protocols for controlling surgical pain while addressing the new mandate to prevent opioid dependence. In this issue, Rao et al. report the current breast and axillary surgery analgesia practices of members of the American Society of Breast Surgeons (ASBrS), and present the Society’s perioperative pain control consensus statement. Roughly 20% of the 3000 ASBrS members who were invited to take the electronic survey responded. They were queried for methods of pain control used (local anesthesia, blocks, nonsteroidal anti-inflammatory drugs [NSAIDs], and opioids) by procedure performed (lumpectomy/excisional biopsy, mastectomy with reconstruction, mastectomy without reconstruction, axillary lymph node dissection [ALND], and oncoplastic rearrangement). Details about the use of each pain control option also were collected. Local anesthesia for excisional biopsies and lumpectomies was used almost unanimously (98%) by survey participants, although less frequently for ALNDs (76%) or mastectomies with or without reconstruction (49% and 55%, respectively). Local anesthesia use was not reported for oncoplastic procedures. Like local anesthesia, NSAIDs were used by nearly all surgeons (96%) for excisional biopsies or lumpectomies, but less frequently (75%) for mastectomies with reconstruction. NSAID use was not reported for mastectomies without reconstruction or for oncoplastic procedures. For the 56% of respondents who reported using preemptive (immediately preoperative) analgesia, only 57% used NSAIDs. Surgeons who avoid NSAIDs likely worry about hematoma formation, although the literature does not support this concern. There was significant variability in the use of regional anesthesia for mastectomies with and without reconstruction despite its documented efficacy. Thirty-three percent of surgeons reported never using nerve blocks for patients undergoing mastectomies with reconstruction, and 43% of surgeons did not use this analgesic strategy at all for patients undergoing mastectomies without reconstruction. The survey, however, did not define ‘‘block’’ and presented only the examples of paravertebral, pectoral nerve, and serratus plane blocks. Epidural anesthesia and intercostal nerve blocks, for instance, also are effective modalities for regional pain control. Society of Surgical Oncology 2020

Underutilization of Enhanced Recovery After Surgery (ERAS) in Breast Surgery: An Opportunity to Reduce Opioid Usage