1
|
Butler I, Taheri P, Khanna P, Gereta S, Hariprasad K, Ancha N, Charles Osterberg E. Decreased Opioid Prescription With Low Pain Scores After Urethroplasty: Using a Simplified, Multimodal, Opioid Minimization Pain Protocol. Urology 2024; 186:24-30. [PMID: 38367712 DOI: 10.1016/j.urology.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/31/2023] [Accepted: 01/25/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVE To implement a simplified, opioid-minimized, multimodal pain management (MPM) protocol and assess its effectiveness of reducing opioid dispersion while maintaining low postoperative complications, patient-reported pain, and patient-reported interference with quality of life (QOL) for men undergoing urethroplasty. METHODS Ninety-five men at a single academic center from October 2020 to October 2023 received a urethroplasty. We retrospectively reviewed the prior standard pain management (SPM) cohort before August 2021, then prospectively studied the MPM cohort after August 2021. For the SPM cohort, we collected postoperative day (POD) 1 pain scores from our Electronic Medical Record (EMR). For the MPM cohort, we obtained a validated pain and QOL assessment in the early postoperative period. The SPM cohort's POD 1 pain scores were compared with the MPM cohort's POD 2 pain scores. Opioid dispensation records were queried from the Prescription Monitoring Program. RESULTS Seventy-five morphine milligram equivalent fewer opioids in the MPM cohort were prescribed than the SPM cohort (0 (interquartile range [IQR]: 0-0) vs 75 (IQR:0-150), P < .001, respectively). Patients with opioid discharge prescriptions fell from 50% in the SPM cohort to 11% in the MPM cohort (P < .001). Early postoperative pain scores remained low and showed no significant difference between the cohorts. Pain's interference with QOL measures remained low. Complications were rare across both cohorts. CONCLUSION This simplified, multimodal analgesia protocol effectively decreases postoperative pain and opioid dispersion without affecting QOL outcomes after urethroplasty. This pain regimen can be easily adopted to decrease the use of postoperative opioids in men undergoing urethroplasty.
Collapse
Affiliation(s)
- Imani Butler
- Dell Medical School, The University of Texas at Austin, Austin, TX.
| | - Pegah Taheri
- Dell Medical School, Department of Surgery and Perioperative Care, Division of Urology, Austin, TX
| | - Prachi Khanna
- Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Sofia Gereta
- Dell Medical School, The University of Texas at Austin, Austin, TX
| | | | - Nirupama Ancha
- Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Edward Charles Osterberg
- Dell Medical School, Department of Surgery and Perioperative Care, Division of Urology, Austin, TX
| |
Collapse
|
2
|
Cabo JJS, Miller NL. Nonopioid Pain Management Pathways for Stone Disease. J Endourol 2024; 38:108-120. [PMID: 38009214 DOI: 10.1089/end.2023.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.
Collapse
Affiliation(s)
- Jackson J S Cabo
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nicole L Miller
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
3
|
Nam CS, Lai YL, Hu HM, George AK, Linsell S, Ferrante S, Brummett CM, Waljee JF, Dupree JM. Less is More: Fulfillment of Opioid Prescriptions Before and After Implementation of a Modifier 22 Based Quality Incentive for Opioid-Free Vasectomies. Urology 2023; 171:103-108. [PMID: 36243141 DOI: 10.1016/j.urology.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/03/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To examine the percentage of patients who filled peri-procedural opioid prescriptions before and after Blue Cross Blue Shield of Michigan (BCBSM) launched a modifier 22 payment incentive for opioid-sparing vasectomies in Michigan on July 1, 2019. METHODS We evaluated BCBSM administrative claims data from February 1, 2018 - November 16, 2020 for men 20 - 64 years old who underwent vasectomy or a control office-based urologic procedure (cystourethroscopy, prostate biopsy, circumcision, and transurethral destruction of prostate tissue.) The primary outcome was the percentage of patients who filled opioid prescriptions 30 days before to 3 days after their procedure. We performed an interrupted time series analysis to estimate changes in the percentage of patients who filled opioid prescriptions in the vasectomy and control group before and after July 1, 1019. RESULTS Our cohort included 4,559 men who had a vasectomy and 4,679 men who had a control procedure. Within each group, demographics and clinical factors were similar before and after July 1, 2019. Before implementation of the modifier 22 policy, 32.5% of men who had a vasectomy filled an opioid prescription whereas only 12.6% of men filled an opioid prescription after July 1, 2019 -a 19.9% absolute reduction and 61.0% relative reduction (P < .001). In the control group, there was no significant change in the percentage of patients who filled opioid prescriptions before and after July 1, 2019 (0.8% absolute increase, P = .671). CONCLUSION Implementation of modifier 22 based financial incentive for opioid-sparing vasectomies was associated with decrease in the percentage of men who filled opioid prescriptions after vasectomy.
Collapse
Affiliation(s)
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Hsou Mei Hu
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Arvin K George
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Susan Linsell
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Stephanie Ferrante
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI; Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Jennifer F Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - James M Dupree
- Department of Urology, Michigan Medicine, Ann Arbor, MI.
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Bevill MD, Schubbe ME, Flynn KJ, Said MA, Ten Eyck P, Tracy CR. PROSPECTIVE COMPARISON OF OPIOID VERSUS NON-OPIOID PAIN REGIMEN AFTER URETEROSCOPY. J Endourol 2022; 36:734-739. [DOI: 10.1089/end.2021.0719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mark D Bevill
- University of Iowa, Urology, Iowa City, Iowa, United States
| | | | - Kevin J. Flynn
- University of Iowa, Urology, Iowa City, Iowa, United States
| | | | - Patrick Ten Eyck
- University of Iowa, Biostatistics, Iowa City, Iowa, United States
| | - Chad Robert Tracy
- University of Iowa, Urology, 200 Hawkins Dr., 3 RCP, Iowa City, Iowa, United States, 52242-1089, ,
| |
Collapse
|