Impact of Enhanced Recovery after Surgery Protocols on Opioid Prescriptions at Discharge after Major Urological Cancer Surgery

Abstract

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.

Interventions to Reduce Opioid Prescriptions following Urological Surgery: A Systematic Review and Meta-Analysis

“…Nineteen studies (8,407 patients; 4,443 in the pre- and 4,031 in the post-intervention cohort) reported sufficient data on prescribed opioids in both cohorts to allow for pooled analysis. 10–25,28,30–32 A significant reduction in prescribed opioids at discharge was noted in all except 1 study following the implementation of various interventions. The mean overall reduction in the post-intervention cohort was −67.59 MME (95% CI 54.23–80.94, p <0.001, I 2 =95%; fig.…”

“…10–32 Direct interventions to reduce opioid prescriptions were evaluated in 16 studies 11,12,14,15,18–21,25–29,31 (7,086 patients), while 6 studies 10,13,16,24,30,32 (1,818 patients) evaluated the effects of various indirect interventions. In 12 studies, 10,11,14,16,19,21,24–26,29,30,32 the procedures were categorized as major surgery, while 7 studies 12,13,18,20,22,23,27 included minor procedure and 3 studies 16,28,31 included both. All studies were either case-control or cohort studies, and there were no reports from randomized controlled trials.…”

“…Of the 8,904 patients from 22 studies used for the qualitative review, 4,560 patients were in the pre-intervention cohort and 4,251 patients in the post-intervention cohort. 10–32 Direct interventions to reduce opioid prescriptions were evaluated in 16 studies 11,12,14,15,18–21,25–29,31 (7,086 patients), while 6 studies 10,13,16,24,30,32 (1,818 patients) evaluated the effects of various indirect interventions. In 12 studies, 10,11,14,16,19,21,24–26,29,30,32 the procedures were categorized as major surgery, while 7 studies 12,13,18,20,22,23,27 included minor procedure and 3 studies 16,28,31 included both.…”

“…Sixteen studies provided data on the type of procedures performed which could be categorized as either major (10 studies, 10,11,14,16,19,21,24,25,30,32 3,062 patients) or minor surgery (6 studies, 12,13,18,20,22,23 1,547 patients). Significant reduction in opioid prescriptions was noted within each surgical category.…”

Enhanced Recovery After Surgery Patients Are Prescribed Fewer Opioids at Discharge

“…26 However, the association of ERAS implementation with discharge opioid prescribing is understudied, and select studies in single specialty cohorts show mixed results. 27,28…”