Opt-In Decision Making Program for Opioids after Breast Surgery Shows Promise in Reducing Prescriptions

Lofftus SY, Graham DS, Le J, Zhu CY, et al. Patient-Based Decision Making for Opioid Prescriptions After Ambulatory Breast Operation: A Randomized Clinical Trial. J Am Coll Surg. April 2026.

In a single-center randomized clinical trial of 107 adults undergoing ambulatory breast surgery between 2022 and 2024, patients were randomized 1:1 to a postoperative opt-in opioid strategy (POINT; n = 56) or routine opioid prescribing (control; n = 51).

Within the POINT arm, 37 patients (66%) declined an opioid prescription and only 19 (34%) opted in. The opt-in strategy substantially reduced opioid exposure at every prescribing endpoint: prescription rates fell from 100% in controls to 35% with POINT, an absolute reduction of 65%, while the proportion of actual opioid consumers decreased from 24% to 9%, an absolute reduction of 15%. Total pills prescribed were reduced from 362 in the routine-prescribing group to 111 in the POINT group, and excess pills were similarly reduced from 293 to 95.

On a per-patient basis, median pills prescribed were 0 (IQR 0–5) with POINT versus 6 (IQR 5–7) in controls (p<0.0001), and median excess pills were likewise 0 (IQR 0–5) versus 6 (IQR 5–7) (p<0.0001). Although total pills consumed differed numerically between groups, the central clinical finding was that most patients in both groups used no opioids at all, with a median consumption of 0 pills (IQR 0) in both arms despite a statistically significant difference in aggregate use (p = 0.04).

Importantly, this marked reduction in opioid prescribing was not associated with inferior patient-centered outcomes. Peak postoperative pain scores across POD 1–7 were noninferior in the opt-in arm, using a prespecified noninferiority margin of 2 points on a 0–10 numeric rating scale, and PROMIS-29 quality-of-life changes were similar between groups. On multivariable analysis, pain severity was the only independent predictor of opioid use, with each increase in pain associated with more than doubled odds of opioid consumption (OR 2.14, 95% CI 1.41–3.26; p=0.00037).

These data suggest that routine default opioid prescribing after ambulatory breast surgery substantially overestimates patient need, and that a patient-directed opt-in model can safely eliminate a large volume of unused opioid tablets without compromising recovery, pain control, or short-term quality of life.