Kathryn Hacker (University of North Carolina at Chapel Hill), Hannah Cook (UNC Eshelman School of Pharmacy), Jae Jung (UNC Eshelman School of Pharmacy), J. Lee Graves (UNC School of Medicine), Peggy McNaull (UNC School of Medicine), Brooke Chidgey (UNC School of Medicine), Jami Mann (UNC Hospitals), Angela Smith (UNC School of Medicine), Matthew Nielsen (UNC School of Medicine)
The incidence of new persistent opioid use following surgery is 6-10%, more common than any single post-operative complication. Additionally, recent systematic review found 67-92% of patients report unused opioid medications after a surgical prescription. Reducing opioid oversupply may substantially impact the opioid epidemic as a primary and secondary prevention strategy.
To evaluate post-surgical opioid requirements of patients following urologic surgeries and create standardized prescribing schedules to reduce oversupply of opioid prescriptions.
Patients undergoing urologic procedures associated with 49 specified CPT codes were identified. Details regarding medications prescribed for postoperative pain were obtained through our pharmacy database. Two weeks post-procedure, patients were contacted via telephone to participate in a survey evaluating postoperative opioid usage, storage, and disposal habits.
During the study period, 877 patients underwent urologic procedures. We contacted 606 patients, and 264 patients completed the survey. Among survey respondents, 75% had unused opioids from their initial postoperative prescription, and the average amount of narcotics used was 55% of the initial prescription. In the 6 month study period, approximately 2800 opioid pills remained unused. In addition to usage data, we also surveyed patients on counseling and disposal information. Among survey respondents, only 31% reported having received counseling on proper opioid storage. Post-operatively, patients stored opioid medications in the following locations: medicine cabinet (34%), kitchen cabinet (18%), out in the open (21%), in a drawer (13%), in a closet (3%), and in another location (9%, including tool box, purse, refrigerator, etc). Only 13% of these locations were locked, preventing unauthorized access to the opioid prescription. Additionally, only 18% of patients with unused opioid medication reported disposing of this medication. Reasons for not disposing of the unused opioid medication included: not considering disposal (36%), saving it in case the patient needed additional medication (47%), not knowing how to properly dispose of it (4%), and other (13%). To reduce the oversupply of opioid medications following urologic procedures, we subsequently developed standardized post-operative opioid prescribing schedules.
Consistent with observations in other surgical populations, we identified substantial oversupply from standard prescribing practices following urologic procedures. Extrapolating this number across the US, the 11,703 practicing urologists described in the AUA 2015 census prescribe approximately 24 million excess opioid pills each year. Given the lack of proper storage and disposal of these medications, this excess opioid supply may contribute to the national crisis of opioid misuse and diversion.
Implications for the Patient
Newly developed data-driven post-operative prescribing schedules coupled with education on appropriate disposal provide an opportunity for urologists to take an active role in opioid stewardship and reduce oversupply and diversion of narcotic medications.