SP22. The Effects of Intraoperative Methadone on Transgender and Gender-diverse Patients Receiving Vaginoplasty

PURPOSE: Reducing surgical patients’ postoperative opioid requirements is important as excessive consumption is associated with substance misuse. This is especially pertinent to transgender and gender diverse (TGD) patients, as they experience high rates of substance use disorder. Maintaining adequate analgesia, however, is equally important to prevent adverse surgical outcomes. Literature from cardiac and neurological patients suggests intraoperative methadone, relative to short-acting opioids (SAO), is associated with lower postoperative morphine milligram equivalents (MME) consumption and pain scores. However, this may not be generalizable to TGD patients undergoing genital surgeries. The present study addresses this gap. METHODS: We utilized retrospective cohort data from TGD patients receiving vaginoplasty at one academic institution between February 2021 and September 2023. Surgical technique and perioperative pain protocols were assessed to ensure similarity between surgeons. Outcomes included opioid MME consumption and average pain scores at postoperative days (POD) zero, one, two, and three. The treatment group included methadone-only, methadone + SAO, and SAO-only. Missing data were imputed with multiple imputations by chained equations. We utilized hurdle models with multivariate logistic and linear regressions to address excess zeros in outcomes. RESULTS: This study included 212 patients. Daily MME consumption and average pain scores for all patients are reported in Table 1. Patients given methadone or methadone + SAO had significantly lower odds of needing any postoperative opioids at all four PODs (p < 0.001). Among patients who used postoperative opioids, total MME was higher for methadone + SAO patients at POD0 only (p = 0.033). At POD2, methadone-only patients consumed less MME than SAO-only patients (p = 0.025). Regarding pain, methadone-only and methadone + SAO patients were significantly less likely to report pain at all four PODs (Table 3, p< 0.001). Among patients who reported pain scores above 0, methadone-only and methadone + SAO patients reported lower scores at POD 1 (p < 0.001). At POD2, methadone-only patients reported lower pain scores than SAO-only patients (p = 0.033). CONCLUSION: Our study suggests that intraoperative methadone is associated with significantly less MME consumption and lower pain scores among TGD patients receiving gender-affirming vaginoplasty. Given the study’s retrospective nature, randomized studies are warranted to validate our findings. If future studies show that intraoperative methadone is associated with lower MME consumption and improved pain scores, transitioning to this analgesic may mitigate complications, leading to better functional and aesthetic outcomes. Equally important, it could support an ongoing effort to prevent the development of substance misuse in a marginalized community seeking gender-affirming care.