Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery

Abstract

BackgroundSurgeons play a pivotal role in combating the opioid crisis that currently grips the United States. Changing surgeon behavior is difficult, and the degree to which behavioral science can steer surgeons toward decreased opioid prescribing is unclear.MethodsThis was a single‐institution, single‐arm, pre‐ and postintervention study examining the prescribing of opioids by urologists for adult patients undergoing prostatectomy or nephrectomy. The primary outcome was the quantity of opioids prescribed in oral morphine equivalents (OMEs) after hospital discharge. The primary exposure was a multipronged behavioral intervention designed to decrease opioid prescribing. The intervention had 3 components: 1) formal education, 2) individual audit feedback, and 3) peer comparison performance feedback. There were 3 phases to the study: a pre‐intervention phase, an intervention phase, and a washout phase.ResultsThree hundred eighty‐two patients underwent prostatectomy, and 306 patients underwent nephrectomy. The median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients (P < .05 for both). The median OMEs prescribed did not increase during the washout phase. Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (P < .05). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity levels, psychiatric symptoms, or somatic symptoms (P > .05 for all).ConclusionsImplementing a multipronged behavioral intervention significantly reduced opioid prescribing for patients undergoing prostatectomy or nephrectomy without compromising patient‐reported outcomes.

Editorial Comment

“…At our institution, we instituted a multipronged behavioral intervention which decreased the median oral morphine equivalents at discharge from 200 to 0 in nephrectomy patients regardless of whether surgery was performed open or using minimally invasive methods. 3 If our institution, and others, have effectively stopped giving opioids for kidney surgery it begs the question on why nationwide urologists haven't curbed their enthusiasm for opioid prescribing. Hopefully, the vice grip of the COVID virus can change the hearts of kidney surgeons as the rise in opioid deaths ascends on a grave new trend line.…”

Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic

“…Although the national focus is beginning to shift toward curbing excess opioid prescribing for the management of acute pain, 8 the role of surgeons and perioperative opioid prescribing remains an underappreciated contributor to the opioid epidemic. Herein, we seek to highlight the role of perioperative prescribing in the opioid epidemic, the limitations of existing state and national policies, and how physician‐led efforts such as the one reported by Jacobs et al in this issue of Cancer 9 have the potential to drive surgical opioid stewardship.…”

“…In their article, Jacobs et al 9 provide one of the most effective single‐institution examples of engaging surgeons in opioid stewardship after major surgery. They conducted a pre‐post study evaluating discharge opioid prescribing after prostatectomy and nephrectomy and included both open and minimally invasive surgeries.…”

“…Similarly, the Michigan Urological Surgery Improvement Collaborative demonstrated a 40% reduction in prescription size after prostatectomy without affecting patient satisfaction or pain control 45 . Within the Surgical Collaborative of Wisconsin, 46 we have implemented an intervention similar to that of Jacobs et al 9 that consists of educational sessions delivered at biannual meetings and individualized prescribing reports benchmarked against other surgeons and prescribing guidelines. These early successes suggest that the collaborative platform is well suited for overcoming the sluggish uptake of evidence‐based practice change needed to improve perioperative opioid stewardship broadly.…”

“…In the future, it is imperative that we as surgeons recognize our responsibility in combating the opioid epidemic and continue to push for interventions that are scalable across geographic areas and surgical specialties. This will require surgeon engagement locally, regionally, and nationally, and Jacobs et al 9 provide us with a recommendation of how to start.…”