IntroductionEarly recovery after surgery (ERAS) protocols are designed limit the use of opioids during in-patient stay to facilitate recovery and early discharge. However, there are conflicting reports of opioids prescribed at discharge to these patients. We wished to evaluate the effect of early recovery efforts on the opioid prescriptions given at discharge after major urologic cancer surgery. MethodsWe reviewed opioid prescription data from patients discharged from our facility after major urologic cancer surgery from 2016 to 2018, including cystectomy, nephrectomy (total, partial) and prostatectomy. The opioid prescriptions were normalized to hydrocodone-5 mg tablet equivalents. Multivariable analysis was performed to evaluate the effect of various factors on opioid prescriptions at discharge. Results409 patients met the inclusion criteria, with 207 without ERAS and 202 on ERAS protocol. Potent opioid (oxycodone or hydrocodone) use was reduced from 92% to 43% and tramadol use increased from 8% to 57% (p < 0.001). Following ERAS, we noted reduction in opioid prescriptions for prostatectomy (30%, p < 0.001), cystectomy (27%, p = 0.02) and all nephrectomy procedures (32%, p < 0.001). On multivariable analysis for each procedure, ERAS protocol was a significant predictor of opioid prescriptions at discharge. ConclusionsA significant decrease in the opioid prescriptions given at discharge was noted after major urologic cancer surgery with the use of ERAS protocols. There was a significant shift towards the use of less potent opioids. These findings provides a benchmark for further interventions and reduction in the outpatient opioid prescriptions after major urologic surgery.
ImportancePostoperative opioid prescriptions are associated with delayed recovery, perioperative complications, opioid use disorder, and diversion of overprescribed opioids, which places the community at risk of opioid misuse or addiction.ObjectiveTo assess a protocol for eliminating postdischarge opioid prescriptions after major urologic cancer surgery.Design, Setting, and ParticipantsThis cohort study of the no opioid prescriptions at discharge after surgery (NOPIOIDS) protocol was conducted between May 2017 and June 2021 at a tertiary referral center. Patients undergoing open or minimally invasive radical cystectomy, radical or partial nephrectomy, and radical prostatectomy were sorted into the control group (usual opioids), the lead-in group (reduced opioids), and the NOPIOIDS group (no opioid prescriptions).InterventionsThe NOPIOIDS group received a preadmission educational handout, postdischarge instructions for using nonopioid analgesics, and no routine opioid prescriptions. The lead-in group received a postdischarge instruction sheet and reduced opioid prescriptions at prescribers’ discretion. The control group received opioid prescriptions at prescribers’ discretion.Main Outcomes and MeasuresPrimary outcome measures included rate and dose of opioid prescriptions at discharge and for 30 days postdischarge. Additional outcome measures included patient-reported pain and satisfaction level, unplanned health care utilization, and postoperative complications.ResultsOf 647 opioid-naive patients (mean [SD] age, 63.6 [10.0] years; 478 [73.9%] male; 586 [90.6%] White), the rate of opioid prescriptions at discharge for the control, the lead-in, and the NOPIOIDS groups was 80.9% (157 of 194), 57.9% (55 of 95), and 2.2% (8 of 358) (Kruskal-Wallis test of medians: P &lt; .001), and the overall median (IQR) tablets prescribed was 14 (10-20), 4 (0-5.3), and 0 (0-0) per patient in the control, lead-in, and NOPIOIDS groups, respectively (Kruskal-Wallis test of medians: P &lt; .001). In the NOPIOIDS group, median and mean opioid dose was 0 tablets for all procedure types, with the exception of kidney procedures (mean [SD], 0.5 [1.7] tablets). Patient-reported pain surveys were received from 358 patients (72.6%) in the NOPIOIDS group, demonstrating low pain scores (mean [SD], 2.5 [0.86]) and high satisfaction scores (mean [SD], 86.6 [3.8]). There was no increase in postoperative complications in the group with no opioid prescriptions.Conclusions and RelevanceThis perioperative protocol, with emphasis on nonopioid alternatives and patient instructions, may be safe and effective in nearly eliminating the need for opioid prescriptions after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery.
Purpose: Opioid prescriptions after surgery are major contributors to the opioid abuse epidemic. Several measures designed to limit opioid prescriptions at discharge have been evaluated. We conducted a comprehensive review and metaanalysis of the effectiveness of various types of interventions in reducing opioid prescriptions after urological surgery. Materials and Methods: A systematic review including MEDLINEÒ, Web of ScienceÔ and Cochrane databases was conducted to identify studies on opioid prescriptions and urological surgery. Twenty-two studies met the inclusion criteria, of which 19 were used for quantitative analysis for reduction in opioid prescriptions. Additional outcomes included opioid consumption and satisfaction with analgesia. Results: Of the 8,318 patients, 53% were in the pre-and 47% in the postintervention cohort. Overall mean reduction/patient in prescribed opioids was À67.59 (95% CI 54.23 to 80.94) morphine milligram equivalents (MME). Direct interventions, implemented by providers within their local department or hospital, were more effective in reducing prescribed opioids compared to indirect, or systemic, interventions, at À76.68 MME (95% CI 60.04 to À93.31) vs À46.72 MME (95% CI 24.20 to À69.23; p[0.04). Opioid consumption significantly decreased post-intervention with a mean reduction of -18.31 MME (95% CI 7.89 to 28.72). Patient satisfaction with analgesia remained unchanged between the pre-and post-intervention groups. Conclusions: Successful reduction in opioid prescriptions, without compromising pain control, can be achieved through a variety of interventions. Direct interventions appear to have a greater impact than indirect interventions in reducing opioid prescriptions. Despite the reduction, unused, excess prescription opioids were still noted, which provides an opportunity for further control on opioid prescriptions.
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