From the 2018 HVPAA National Conference
Hiten Patel (Johns Hopkins Brady Urological Institute), Arnav Srivastava (Johns Hopkins Brady Urological Institute), Farzana Faisal (Johns Hopkins Brady Urological Institute), Wesley Ludwig (Johns Hopkins Brady Urological Institute), Zeyad Schwen (Johns Hopkins Brady Urological Institute), Gregory Joice (Johns Hopkins Brady Urological Institute), Mohamad Allaf (Johns Hopkins Brady Urological Institute), Misop Han (Johns Hopkins Brady Urological Institute), Amin Herati (Johns Hopkins Brady Urological Institute)
Surgeons account for one-third of all opioid prescriptions despite decreased morbidity for many procedures in recent years. Additionally, there is minimal evidence on post-discharge opioid use by patients across all surgical fields for any specific procedure, hindering the development of evidence-based recommendations for prescribing.
The aim of our study was to (1) assess providers’ opioid recommendations after radical prostatectomy (RP), (2) prospectively measure post-discharge analgesia use and disposal, and (3) standardize prescribing to reduce practice variation and overall opioid prescribing
Between April and June 2017, surveys were conducted at a single institution to assess provider (urology faculty and residents) perceptions about post-discharge opioid pain medication prescribing practices. The Opioid Reduction Intervention for Open, Laparoscopic, and Endoscopic Surgery (ORIOLES) Initiative was designed as a pre-post study to prospectively quantify post-discharge analgesia use after RP from August 2017 to January 2018. Opioid prescribing for consecutive patients undergoing RP was assessed with outcomes evaluated at 30-day follow-up phone calls to quantify the amount of opioids and other analgesics used in relation to amounts prescribed and method of disposal for excess opioids. Oral morphine equivalents (OMEQ) were calculated.
Of 27 providers surveyed, 54% responded to each survey. The majority (83%) felt opioids were prescribed for procedures not requiring them or with superfluous quantities. Reducing post-operative phone calls and visits was the largest contributor (75%). All providers recommended 2 weeks supply or less with a weighted average recommended OMEQ of 180mg (120mg oxycodone or 24x5mg pills). Data from 205 RP patients showed 203 (99.0%) received an opioid prescription and 184 (88.8%) had one filled. While the average OMEQ prescribed was 227mg (126% of recommended by survey respondents; 37 (18%) received <180mg OMEQ), only 52mg on average was used (23% of OMEQ prescribed; ~6.9x5mg oxycodone pills). 68 (33.2%) patients did not consume any opiates. 162/205 (79%) required 90mg OMEQ or less (12x5mg oxycodone pills) with 146 (71%) and 64 (31%) reporting acetaminophen or NSAID use, respectively. Only 22/173 (12.7%) disposed of remaining pills by 30 days despite none requiring pain medication related to surgery at the time (3.5% flushed, 2.9% thrown in trash, 1.7% returned to pharmacy, 4.6% other). Linear regression models showed age, operative time, and surgical approach were not associated with increased opioid use.
Only 23% of prescribed post-discharge opioid pain medications were required after RP with 80% requiring 90mg OMEQ or less. In order to combat the opioid crisis, re-calibration of surgeon prescribing patterns is needed based on data for specific procedures and incorporation of multimodal pain regimens and patient counseling. The ORIOLES Initiative has now implemented the intervention arm with standardized prescribing (15x5mg oxycodone pills) and patient counseling after RP through nursing education and a discharge sheet to measure post-discharge opioid prescribing, use, and appropriate disposal.
Implications for the Patient
Surgeons prescribe over four-times as much post-discharge opioid analgesia after RP than patients require. The ORIOLES Initiative has established recommendations for opioid prescribing after RP based on prospective evidence; it has implemented measures to reduce variation and improve analgesia use and opioid disposal in a prospective intervention arm.