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Anderson DJ, Cao DY, Zhou J, McDonald M, Razzak AN, Hasoon J, Viswanath O, Kaye AD, Urits I. Opioids in Urology: How Well Are We Preventing Opioid Dependence and How Can We Do Better? Health Psychol Res 2022; 10:38243. [PMID: 36118983 PMCID: PMC9476236 DOI: 10.52965/001c.38243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Urologic procedures (both open and minimally invasive) can cause pain due to the surgery itself, devices placed, and post-operative issues. Thus, pain management is important for every post-procedure recovery period. Opioid use post-surgery is common and often over-prescribed contributing to persistent use by patients. In this article, we review the extent of opioid use in pediatric urologic procedures, vasectomy, endourologic procedures, penile implantation, urogynecologic procedures, prostatectomy, nephrectomy, cystectomy, and scrotal/testicular cancer surgery. Generally, we have found that institutions do not have a standardized protocol with a set regimen to prescribe opioids, resulting in more opioids being prescribed than needed and patients not properly disposing of their unused prescriptions. However, many institutions recognize their opioid overuse and are implementing new multimodal opioid-sparing analgesics methods such as non-opioid peri-operative medications, minimally invasive robotic surgery, and nerve blocks or local anesthetics with varying degrees of success. By shedding light on these opioid-free methods and prescription protocols, along with improved patient education and counselling, we hope to bring awareness to institutions and decrease unnecessary opioid use.
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Affiliation(s)
| | - David Y Cao
- School of Medicine, Medical College of Wisconsin
| | - Jessica Zhou
- School of Medicine, Medical College of Wisconsin
| | - Matthew McDonald
- School of Medicine, Rocky Vista University College of Osteopathic Medicine
| | | | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Omar Viswanath
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Valley Anesthesiology and Pain Consultants, Envision Physician Services; Department of Anesthesiology, University of Arizona College of Medicine Phoenix; Department of Anesthesiology, Creighton University School of Medicine
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Anesthesiology, Louisiana State University Health Shreveport
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Stensland KD, Chang P, Jiang D, Canes D, Berkenwald A, Waisman A, Robinson K, Brat G, Crociani C, Mcanally K, Hyde S, Holliday B, Mechaber J, Baraka A, Moinzadeh A, Wagner AA. Reducing postoperative opioid pill prescribing via a quality improvement approach. Int J Qual Health Care 2021; 33:6311507. [PMID: 34189572 DOI: 10.1093/intqhc/mzab099] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/26/2021] [Accepted: 06/25/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption. OBJECTIVE To address excess opioid prescribing within our institutions, we applied a plan-do-study-act (PDSA)-like quality improvement strategy to assess local opioid prescribing and use, modify our institutional protocols, and assess the impacts of the change. The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption. We describe our approach, findings, and lessons learned from our quality improvement approach. METHODS We prospectively recorded home pain pill usage after robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) at two academic institutions from July 2016 to July 2019. Patients prospectively recorded their home pain pill use on a take-home log. Other factors, including numeric pain rating scale on the day of discharge, were extracted from patient records. We analyzed our data and modified opioid prescription protocols to meet the reported use data of 80% of patients. We continued collecting data after the protocol change. We also used our prospectively collected data to assess the accuracy of a retrospective phone survey designed to measure postdischarge opioid use. Our primary outcomes were the proportion of patients taking zero opioid pills postdischarge, median pills taken after discharge and the number of excess pills prescribed but not taken. We compared these outcomes before and after protocol change. RESULTS A total of 266 patients (193 RALP, 73 RAPN) were included. Reducing the standard number of prescribed pills did not increase the percentage of patients taking zero pills postdischarge in either group (RALP: 47% vs. 41%; RAPN 48% vs. 34%). The patients in either group reporting postoperative Day 1 pain score of 0 or 1 were much more likely to use zero postdischarge opioid pills. Our reduction in prescribing protocol resulted in an estimated reduction in excess pills from 1555 excess pills in the prior protocol to just 155 excess pills in the new protocol. CONCLUSION Our PDSA-like approach led to an acceptable protocol revision resulting in significant reductions in excess pills released into the community. Reducing the quantity of opioids prescribed postoperatively does not increase the percentage of patients taking zero pills postdischarge. To eliminate opioid use may require no-opioid pathways. Our approach can be used in implementing zero opioid discharge plans and can be applied to opioid reduction interventions at other institutions where barriers to reduced prescribing exist.
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Affiliation(s)
- Kristian D Stensland
- Department of Urology, University of Michigan, Ann Arbor, MI.,Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Peter Chang
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David Jiang
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David Canes
- Division of Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Aaron Berkenwald
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Adrian Waisman
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kortney Robinson
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gabriel Brat
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Catrina Crociani
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kyle Mcanally
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sarah Hyde
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Brian Holliday
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jodi Mechaber
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Analesa Baraka
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alireza Moinzadeh
- Division of Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Andrew A Wagner
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Klaassen Z, Wallis CJD. Addressing Mental Health in Urology Patients: The Time is Now. Eur Urol Focus 2020; 6:1137-1139. [PMID: 32891584 PMCID: PMC7468339 DOI: 10.1016/j.euf.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 08/25/2020] [Indexed: 10/29/2022]
Affiliation(s)
- Zachary Klaassen
- Division of Urology, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA; Georgia Cancer Center, Augusta, GA, USA.
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Krimphove MJ, Reese SW, Chen X, Marchese M, Pucheril D, Cone E, Chou W, Tully KH, Kibel AS, Urman RD, Chang SL, Kluth LA, Dasgupta P, Trinh QD. Recovery from minimally invasive vs. open surgery in kidney cancer patients: Opioid use and workplace absenteeism. Investig Clin Urol 2020; 62:56-64. [PMID: 33314804 PMCID: PMC7801161 DOI: 10.4111/icu.20200194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/23/2020] [Accepted: 07/09/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Does surgical approach (minimally invasive vs. open) and type (radical vs. partial nephrectomy) affects opioid use and workplace absenteeism. Materials and Methods Retrospective multivariable regression analysis of 2,646 opioid-naïve patients between 18 and 64 undergoing radical or partial nephrectomy via either a minimally invasive vs. open approach for kidney cancer in the United States between 2012 and 2017 drawn from the IBM Watson Health Database was performed. Outcomes included: (1) opioid use in opioid-naïve patients as measured by opioid prescriptions in the post-operative setting at early, intermediate and prolonged time periods and (2) workplace absenteeism after surgery. Results Patients undergoing minimally invasive surgery had a lower odds of opioid use in the early and intermediate post-operative periods (early: odds ratio [OR], 0.77; 95% confidence interval [CI], 0.62–0.97; p=0.02, intermediate: OR, 0.60; 95% CI, 0.48–0.75; p<0.01), but not in the prolonged setting (prolonged: OR, 1.00; 95% CI, 0.75–1.34; p=0.98) and had earlier return to work (minimally invasive vs. open: −10.53 days; 95% CI, −17.79 to −3.26; p<0.01). Controlling for approach, patient undergoing partial nephrectomy had lower rates of opioid use across all time periods examined and returned to work earlier than patients undergoing radical nephrectomy (partial vs. radical: −14.41 days; 95% CI, −21.22 to −7.60; p<0.01). Conclusions Patients undergoing various forms of surgery for kidney cancer had lower rates of peri-operative opioid use, fewer days of workplace absenteeism, but no difference in long-term rates of opioid use in patients undergoing minimally invasive as compared to open surgery.
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Affiliation(s)
- Marieke J Krimphove
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Stephen W Reese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Xi Chen
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maya Marchese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Pucheril
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eugene Cone
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wesley Chou
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karl H Tully
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Adam S Kibel
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven L Chang
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Prokar Dasgupta
- Department of Urology, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Guy's Hospital, London, United Kingdom
| | - Quoc Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Abstract
PURPOSE OF REVIEW Surgeons have played a significant role in the current opioid epidemic through overprescribing practices in the postoperative setting. However, contemporary efforts have helped to decrease opioid excess, particularly in the field of urology. Minimally invasive surgery offers a unique avenue to address overuse of narcotics in the postoperative period given its emphasis on enhanced recovery. RECENT FINDINGS Historically, the majority of the literature characterizing postoperative opioid use and its reduction has focused on non-urological surgery. However, recent studies have shown that patients undergoing urologic procedures are prescribed opioids in a similar manner as patients in other surgical specialties. Reduction strategies have been implemented through the use of regional anesthesia, enhanced recovery after surgery pathways, and the development of procedure-specific opioid prescription recommendations. Patients undergoing urologic surgery experience the same risk of opioid misuse and abuse as patients undergoing other types of surgery. However, the wide use of minimally invasive urological surgeries including robotic surgery offers a unique opportunity to reduce postoperative opioid use through multimodal and interdisciplinary protocols and standardizing guidelines.
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Affiliation(s)
- Juan Serna
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Jordan Medical Education Center, 6th Floor, 3400 Civic Center Blvd., Building 421, Philadelphia, PA, 19104, USA.
| | - Ruchika Talwar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Lee
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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