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Galansky L, Shah M, Sholklapper T, Crigger C, Patel HD, Harris K, Wang MH, Wu C, Gearhart JP, Gabrielson AT, Di Carlo HN. A Double-Blinded Randomized Controlled Trial Assessing the Efficacy of Opioid Disposal Instructions with Parental Education on Proper Opioid Disposal Rates Following Ambulatory Pediatric Urologic Surgery. Urology 2024:S0090-4295(24)00689-7. [PMID: 39173931 DOI: 10.1016/j.urology.2024.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/04/2024] [Accepted: 08/09/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVES To determine if the administration of standardized opioid disposal instructions with focused parental education improves proper disposal of leftover opioid medication among families of children undergoing ambulatory urologic surgery compared to routine postoperative instructions. METHODS A prospective, double-blinded, single-center randomized controlled trial was conducted in children 6-18 years undergoing ambulatory urology procedures between October 2021 and April 2023. Patients were randomized (1:1) to receive either the Food and Drug Administration (FDA) opioid disposal best practices worksheet plus nursing parental education or routine postoperative instructions alone. All patients were prescribed acetaminophen and ibuprofen and a per-protocol rescue opioid prescription. The primary outcome was rate of proper opioid disposal at 10-14 days post-procedure. Secondary outcomes included parents' postoperative pain measure (PPPM) scores, numerical pain scale (NPS) scores, and weight-based opioid utilization at 48 hours and 10-14 days. RESULTS We randomized 104 participants (53 intervention, 51 control) with 97% (101/104) complete follow-up data at 10-14 days. Patient demographics, procedural characteristics, and analgesia use were similar between groups. We observed no significant difference in proper opioid disposal rates between arms (31% intervention vs 18% control; estimated difference in proportion 13% [95% CI, -4%-29%]; P = .1). There were no increased odds of proper disposal of leftover opioid medication at 10-14 days with the intervention compared to the control (OR 2.0 [95% CI 0.8-5.1]; P = .1). We observed no differences in PPPM scores, NPS scores, or opioid utilization at 48 hours or 10-14 days. CONCLUSION Providing formal opioid disposal instructions with parental education did not improve proper disposal of leftover opioid medication nor did it alter post-discharge opioid utilization after pediatric urologic surgery.
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Affiliation(s)
- Logan Galansky
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Manuj Shah
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tamir Sholklapper
- Department of Urology, Albert Einstein Medical Center, Philadelphia, PA
| | - Chad Crigger
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiten D Patel
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kelly Harris
- Department of Urology, University of Colorado School of Medicine, Aurora, CO
| | - Ming-Hsien Wang
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charlotte Wu
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John P Gearhart
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew T Gabrielson
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Heather N Di Carlo
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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Bansal N, Armitage CJ, Hawkes RE, Tinsley S, Ashcroft DM, Chen LC. Decoding behaviour change techniques in opioid deprescribing strategies following major surgery: a systematic review of interventions to reduce postoperative opioid use. BMJ Qual Saf 2024:bmjqs-2024-017265. [PMID: 39074984 DOI: 10.1136/bmjqs-2024-017265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/11/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND AND OBJECTIVES METHODS: A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen's d effect sizes were calculated. BCTs were identified using a validated taxonomy. RESULTS 22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward. CONCLUSIONS Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors. PROSPERO REGISTRATION NUMBER CRD42022290060.
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Affiliation(s)
- Neetu Bansal
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health,Manchester Academic Health Science Centre, Oxford Road, University of Manchester, Manchester, UK
| | - Christopher J Armitage
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Rhiannon E Hawkes
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Sarah Tinsley
- Pharmacy Department, Royal Stoke University Hospitals, Stoke-on-Trent, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Research Collaboration, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Pence ST, Findlay BL, Bearrick EN, Pinkhasov AM, Fadel A, Anderson KT, Viers BR. Evaluation of an Opioid-free Pathway for Perineal Reconstructive Surgery: A 1-year Pilot Study. Urology 2024; 190:110-114. [PMID: 38677369 DOI: 10.1016/j.urology.2024.04.032] [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: 01/30/2024] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE To evaluate the impact of a standardized perioperative pain management pathway on postoperative opioid prescribing practices following male perineal reconstructive surgery at our institution. METHODS Patients undergoing perineal reconstructive surgery (urethroplasty, artificial urinary sphincter, urethral sling) by a single surgeon from July 2022 to June 2023 were prospectively followed. A standardized nonopioid pathway was implemented in the perioperative period. Intraoperative local anesthetic included liposomal bupivacaine mixed with 0.25% bupivacaine. Opioids are administered in the recovery room at the discretion of anesthesiology providers. As of July 2022, our standard practice does not include a postoperative opioid prescription unless pain is poorly controlled in the recovery area. Postoperative communication encounters and opioid prescriptions were tracked through the electronic health record (EHR) in order to assess the efficacy of an opioid-free pathway. RESULTS Sixty-seven patients met the criteria during the study period, 64/67 performed in an outpatient setting. 6/67 (9%) patients were prescribed an opioid postoperatively; 4 related to post-surgical pain, and 2 related to chronic pain. No refills were prescribed. Of the 26 patients who received an opioid in the recovery area, 2 (7.6%) were prescribed an opioid at discharge. 15/67 (22%) patients had a communication encounter related to pain within 30 days, most commonly related to bladder spasm management. Only 2 of these encounters resulted in an electronic opioid prescription. CONCLUSION An opioid-free pathway is appropriate for opioid naive men undergoing perineal reconstructive surgery. When necessary, electronic opioid prescribing should be employed following discharge for breakthrough pain.
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Affiliation(s)
| | | | | | | | | | | | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, MN.
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Xin L, Guo J. Impacts of Perioperative Comprehensive Nursing Intervention on Postoperative Urinary Incontinence and Quality of Life of Patients Undergoing Laparoscopic Radical Prostatectomy. Cancer Invest 2024:1-10. [PMID: 38501256 DOI: 10.1080/07357907.2024.2308173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/17/2024] [Indexed: 03/20/2024]
Abstract
To evaluate the impact of perioperative comprehensive nursing intervention on postoperative urinary incontinence, various aspects of patient well-being were assessed. The comprehensive group, that received the nursing intervention, demonstrated significant improvements in self-care skills, health knowledge level, self-care responsibility, and self-concept compared to the standard group. The findings indicate that perioperative comprehensive nursing intervention has a remarkable effect on patients undergoing laparoscopic radical prostatectomy. This nursing intervention not only effectively improves postoperative urinary incontinence and alleviates negative emotions, such as anxiety and depression. Therefore, the implementation of this nursing intervention model is highly recommended for clinical practice and wider application.
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Affiliation(s)
- Lulu Xin
- Nursing Department, Cangzhou Center Hospital, Cangzhou, Hebei, China
| | - Jinjin Guo
- Department of Urology, Cangzhou Center Hospital, Cangzhou, Hebei, China
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Biesboer EA, Al Tannir AH, Karam BS, Tyson K, Peppard WJ, Morris R, Murphy P, Elegbede A, de Moya MA, Trevino C. A Prescribing Guideline Decreases Postoperative Opioid Prescribing in Emergency General Surgery. J Surg Res 2024; 293:607-612. [PMID: 37837815 DOI: 10.1016/j.jss.2023.09.012] [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] [Received: 05/05/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Patients prescribed higher opioid dosages have a higher risk of persistent opioid use, overdose, and death. There is a lack of standardization for opioid prescribing for acute surgical pain in emergency general surgery (EGS) patients. We hypothesized that implementing a guideline to standardize opioid prescribing would be associated with a decrease in prescribing at hospital discharge for EGS patients without increasing additional postdischarge refills. METHODS This was a quasi-experimental study evaluating opioid prescribing by EGS providers before and after the implementation of a prescribing guideline. Patients were assigned to preguideline and postguideline groups based on admission date surrounding the implementation of the guideline. The primary outcome was the proportion of patients receiving an opioid prescription for ≥50 Morphine Milligram Equivalents (MME) per day on hospital discharge. RESULTS There were 227 patients in the preguideline group and 226 patients in the postguideline group. After guideline implementation, median total MME prescribed decreased from 113 (interquartile range = 75) to 75 (interquartile range = 75, P = 0.03). The proportion of patients receiving a prescription for daily MME ≥50 also decreased from 75% to 25% (P ≤0.01). There were no increases in requested refills (17% versus 16%, P = 0.72) or received refills (14% versus 14%, P = 0.98). Guideline compliance ranged from 75% in ventral hernia repair patients to 94% in laparoscopic cholecystectomy patients. CONCLUSIONS A departmental guideline to standardize postoperative opioid prescriptions was associated with a decrease in the amount of MMEs prescribed to EGS patients without an increase in requested or received refills.
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Affiliation(s)
- Elise A Biesboer
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Abdul Hafiz Al Tannir
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Basil S Karam
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katherine Tyson
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William J Peppard
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin
| | - Rachel Morris
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Patrick Murphy
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anuoluwapo Elegbede
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marc A de Moya
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Colleen Trevino
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Mian BM, Singh Z, Carnes K, Lorenz L, Feustel P, Kaufman RP, Avulova S, Bernstein A, Cangero T, Fisher HAG. Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery. JAMA Surg 2023; 158:378-385. [PMID: 36753170 PMCID: PMC9909575 DOI: 10.1001/jamasurg.2022.7652] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/22/2022] [Indexed: 02/09/2023]
Abstract
Importance Postoperative opioid prescriptions are associated with delayed recovery, perioperative complications, opioid use disorder, and diversion of overprescribed opioids, which places the community at risk of opioid misuse or addiction. Objective To assess a protocol for eliminating postdischarge opioid prescriptions after major urologic cancer surgery. Design, Setting, and Participants This cohort study of the no opioid prescriptions at discharge after surgery (NOPIOIDS) protocol was conducted between May 2017 and June 2021 at a tertiary referral center. Patients undergoing open or minimally invasive radical cystectomy, radical or partial nephrectomy, and radical prostatectomy were sorted into the control group (usual opioids), the lead-in group (reduced opioids), and the NOPIOIDS group (no opioid prescriptions). Interventions The NOPIOIDS group received a preadmission educational handout, postdischarge instructions for using nonopioid analgesics, and no routine opioid prescriptions. The lead-in group received a postdischarge instruction sheet and reduced opioid prescriptions at prescribers' discretion. The control group received opioid prescriptions at prescribers' discretion. Main Outcomes and Measures Primary outcome measures included rate and dose of opioid prescriptions at discharge and for 30 days postdischarge. Additional outcome measures included patient-reported pain and satisfaction level, unplanned health care utilization, and postoperative complications. Results Of 647 opioid-naive patients (mean [SD] age, 63.6 [10.0] years; 478 [73.9%] male; 586 [90.6%] White), the rate of opioid prescriptions at discharge for the control, the lead-in, and the NOPIOIDS groups was 80.9% (157 of 194), 57.9% (55 of 95), and 2.2% (8 of 358) (Kruskal-Wallis test of medians: P < .001), and the overall median (IQR) tablets prescribed was 14 (10-20), 4 (0-5.3), and 0 (0-0) per patient in the control, lead-in, and NOPIOIDS groups, respectively (Kruskal-Wallis test of medians: P < .001). In the NOPIOIDS group, median and mean opioid dose was 0 tablets for all procedure types, with the exception of kidney procedures (mean [SD], 0.5 [1.7] tablets). Patient-reported pain surveys were received from 358 patients (72.6%) in the NOPIOIDS group, demonstrating low pain scores (mean [SD], 2.5 [0.86]) and high satisfaction scores (mean [SD], 86.6 [3.8]). There was no increase in postoperative complications in the group with no opioid prescriptions. Conclusions and Relevance This perioperative protocol, with emphasis on nonopioid alternatives and patient instructions, may be safe and effective in nearly eliminating the need for opioid prescriptions after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery.
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Affiliation(s)
- Badar M. Mian
- Department of Urology, Albany Medical Center, Albany, New York
| | - Zorawar Singh
- Department of Urology, Albany Medical Center, Albany, New York
| | - Kevin Carnes
- Department of Urology, Albany Medical Center, Albany, New York
| | - Leanne Lorenz
- Department of Surgery, Albany Medical Center, Albany, New York
| | - Paul Feustel
- Department of Urology, Albany Medical Center, Albany, New York
- Department of Neuroscience and Experimental Therapeutics, Albany Medical Center, Albany, New York
| | | | | | | | - Theodore Cangero
- Department of Information Services, Albany Medical Center, Albany, New York
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Talebi R, Miller C, Abboudi J, Brahmabhatt S, Emper W, Lonner J, Kistler J, Mazur D, Pedowitz D, Ilyas AM. How Patients Dispose of Unused Prescription Opioids: A Survey of over 300 Postoperative Patients. Cureus 2022; 14:e28111. [PMID: 36134102 PMCID: PMC9481200 DOI: 10.7759/cureus.28111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Diversion of unused prescription opioids is a common source of opioid sensitization in the community. Educating patients about safe opioid use has been shown to be effective in decreasing opioid use. However, decreasing diversion will also require educating patients on proper opioid disposal. A survey was administered to better understand patients’ habits with opioid disposal for opioids prescribed after orthopedic surgery. Methods A cross-sectional survey study of 469 patients who had undergone orthopedic surgery was conducted to learn their preferences and habits regarding the disposal of unused prescription opioids received after orthopedic surgery. Results The survey respondents consisted of 48.8% female and 51.2% male patients. Ninety-four point two percent (94.2%) of those receiving opioid prescriptions reported having leftover unused opioids. In terms of voluntary disposal, 68.8% claimed to dispose of their prescription opioids while 31.2% did not. Gender, but not age, had a significant effect on plans for opioid disposal and how seriously respondents viewed issues of opioid misuse. When asked their preferred location for prescription opioid disposal, the most common preference was a local pharmacy. Discussion This survey identified that most patients do not store their prescription opioids in a locked location, claim to dispose of their unused prescription opioids, and would prefer to dispose of them at a pharmacy if possible. This information points to the need for close prescriber-to-pharmacy collaboration to promote the safe disposal of prescription opioids and mitigate drug diversion.
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Turcotte B, Jacques E, Tremblay S, Toren P, Caumartin Y, Lodde M. Opioid use after uro-oncologic surgeries in time of opioid crisis. Can Urol Assoc J 2022; 16:E432-E436. [PMID: 35302470 PMCID: PMC9343155 DOI: 10.5489/cuaj.7633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Recent literature emphasizes how overprescription and lack of guidelines contribute to wide variation in opioid prescribing practices and opioid-related harms. We conducted a prospective, observational study to evaluate opioid prescriptions among uro-oncologic patients discharged following elective in-patient surgery. METHODS Patients who underwent four surgeries were included: open retropubic radical prostatectomy, robot-assisted radical prostatectomy, laparoscopic radical nephrectomy, and laparoscopic partial nephrectomy. The primary outcome was the dose of opioids used after discharge (in oral morphine equivalents [MEq]). Secondary outcomes included: opioid requirements for 80% of the patients, management of unused opioids, opioid use three months postoperative, opioid prescription refills, and guidance about opioid disposal. RESULTS Sixty patients were included for analysis. Patients used a mean of 30 MEq (95% confidence interval 17.8-42.2) at home and 80% of the patients used 50 MEq or less. A mean of 40.4 MEq per patient was overprescribed. Fifty percent of the patients kept the remaining opioids at home, with only 20.0% returning them to their pharmacy. After three months, 5.0% of the patients were using opioids at least occasionally. Three patients needed a new opioid prescription. Forty percent reported having received information regarding management of unused opioids. CONCLUSIONS We found 60% of opioids prescribed were unused, with half of our patients keeping these unused tablets at home. Our results suggest appropriate opioid prescription amounts needed for urological cancer surgery, with 80% of the patients using 50 MEq or less of morphine equivalents.
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Affiliation(s)
- Bruno Turcotte
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Emma Jacques
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Samuel Tremblay
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Paul Toren
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Yves Caumartin
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Michele Lodde
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec, QC, Canada
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Bercu C, Hemal A, Badlani G, Dutta R, Pathak R. Evaluation of a Novel Multimodal Opioid-Free Postoperative Pain Management Pathway Following Robotic-Assisted Radical Prostatectomy: A Pilot Series in the Veteran Population. Clin Genitourin Cancer 2022; 20:e419-e423. [DOI: 10.1016/j.clgc.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/03/2022]
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Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
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Puliatti S, Piazza P, Cacciamani GE, Gómez Rivas J, Taratkin M, Marenco JL, Rivero Belenchon I, Kowalewski KF, Checcucci E. Comment on: "Predictive factors for opioid-free management after robotic radical prostatectomy: the value of a single-port robotic platform". Minerva Urol Nephrol 2021; 73:677-679. [PMID: 34847651 DOI: 10.23736/s2724-6051.21.04724-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Stefano Puliatti
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy.,Orsi Academy, Ghent, Belgium
| | - Pietro Piazza
- Orsi Academy, Ghent, Belgium.,Department of Urology, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Juan Gómez Rivas
- Department of Urology, Hospital Clínico San Carlos, Madrid, Spain
| | - Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - José L Marenco
- Department of Urology, Valencian Institute of Oncology Foundation, Valencia, Spain
| | - Ines Rivero Belenchon
- Department of Urology and Nephrology, Virgen del Rocío University Hospital, Seville, Spain
| | - Karl-Friedrich Kowalewski
- Department of Urology and Urological Surgery, Mannheim University Medical Center, Heidelberg University, Mannheim, Germany
| | - Enrico Checcucci
- Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy - .,Department of Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy
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12
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Su ZT, Becker REN, Huang MM, Biles MJ, Harris KT, Koo K, Han M, Pavlovich CP, Allaf ME, Herati AS, Patel HD. Patient and in-hospital predictors of post-discharge opioid utilization: Individualizing prescribing after radical prostatectomy based on the ORIOLES initiative. Urol Oncol 2021; 40:104.e9-104.e15. [PMID: 34857445 DOI: 10.1016/j.urolonc.2021.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Judicious opioid stewardship would match each patient's prescription to their true medical necessity. However, most prescribing paradigms apply preset quantities and clinical judgment without objective data to predict individual use. We evaluated individual patient and in-hospital parameters as predictors of post-discharge opioid utilization after radical prostatectomy (RP) to provide evidence-based guidance for individualized prescribing. METHODS A prospective cohort of patients who underwent open or robotic RP were followed in the Opioid Reduction Intervention for Open, Laparoscopic, and Endoscopic Surgery (ORIOLES) initiative. Baseline demographics, in-hospital parameters, and inpatient and post-discharge pain medication utilization were tabulated. Opioid medications were converted to oral morphine equivalents (OMEQ). Predictive factors for post-discharge opioid utilization were analyzed by univariable and multivariable linear regression, adjusting for opioid reduction interventions performed in ORIOLES. RESULTS Of 443 patients, 102 underwent open and 341 underwent robotic RP. The factors most strongly associated with post-discharge opioid utilization included inpatient opioid utilization in the final 12 hours before discharge (+39.6 post-discharge OMEQ if inpatient OMEQ was >15 vs. 0), maximum patient-reported pain score (range 0-10) in the 12 hours before discharge (+27.6 OMEQ for pain score ≥6 vs. ≤1), preoperative opioid use (+76.2 OMEQ), and body mass index (BMI; +1.4 OMEQ per 1 kg/m2). A final predictive calculator to guide post-discharge opioid prescribing was constructed. CONCLUSIONS Following RP, inpatient opioid use, patient-reported pain scores, prior opioid use, and BMI are correlated with post-discharge opioid utilization. These data can help guide individualized opioid prescribing to reduce risks of both overprescribing and underprescribing.
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Affiliation(s)
- Zhuo T Su
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Russell E N Becker
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mitchell M Huang
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael J Biles
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly T Harris
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin Koo
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Misop Han
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christian P Pavlovich
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohamad E Allaf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Amin S Herati
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiten D Patel
- Department of Urology, Loyola University Medical Center, Maywood, IL
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13
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Koo K, Winoker JS, Patel H, Faisal F, Gupta N, Metcalf M, Mettee L, Meyer A, Pavlovich C, Pierorazio P, Matlaga BR. Evidence-Based Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery. J Endourol 2021; 35:1838-1843. [PMID: 34107778 DOI: 10.1089/end.2021.0250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus. METHODS A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naïve adult patients after uncomplicated procedures. RESULTS Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement. CONCLUSION Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making prior to prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.
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Affiliation(s)
- Kevin Koo
- Mayo Clinic, 6915, 200 First St SW, Rochester, Minnesota, United States, 55905;
| | - Jared S Winoker
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States;
| | - Hiten Patel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States;
| | - Farzana Faisal
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States;
| | - Natasha Gupta
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States;
| | - Meredith Metcalf
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States;
| | | | - Alexa Meyer
- Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, Baltimore, Maryland, United States;
| | - Christian Pavlovich
- Johns Hopkins, Urology , Suite 3200, Bldg 301, 4940 Eastern Ave, Baltimore, Maryland, United States, 21224;
| | - Philip Pierorazio
- Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, 600 N. Wolfe Street, Marburg 134, Baltimore, Maryland, United States, 21287;
| | - Brian R Matlaga
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States;
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14
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Findlay BL, Britton CJ, Glasgow AE, Gettman MT, Tyson MD, Pak RW, Viers BR, Habermann EB, Ziegelmann MJ. Long-term Success With Diminished Opioid Prescribing After Implementation of Standardized Postoperative Opioid Prescribing Guidelines: An Interrupted Time Series Analysis. Mayo Clin Proc 2021; 96:1135-1146. [PMID: 33958051 DOI: 10.1016/j.mayocp.2020.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/21/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices. PATIENTS AND METHODS Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χ2 tests. Cochran-Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation. RESULTS The median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P<.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P<.001). CONCLUSION In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.
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Affiliation(s)
| | | | - Amy E Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, AZ
| | - Raymond W Pak
- Department of Urology, Mayo Clinic, Jacksonville, FL
| | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- The Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN
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15
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Burns S, Urman R, Pian R, Coppes OJM. Reducing New Persistent Opioid Use After Surgery: A Review of Interventions. Curr Pain Headache Rep 2021; 25:27. [PMID: 33760983 PMCID: PMC7990836 DOI: 10.1007/s11916-021-00943-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize interventions used in the perioperative period to reduce the development of new persistent postoperative opioid use in opioid-naïve patients. RECENT FINDINGS The development of new persistent opioid use after surgery has recently been identified as a common postoperative complication. The existing literature suggests that interventions across the continuum of care have been shown to decrease the incidence of new persistent postoperative opioid use. Specific preoperative, intraoperative, and postoperative interventions will be reviewed, as well as the use of clinical pathways and protocols that span throughout the perioperative period. Common to many of these interventions include the use of multimodal analgesia throughout the perioperative period and an emphasis on a patient-centered, evidence-based approach to the perioperative pain management plan. While the incidence of new persistent postoperative opioid use appears to be high, the literature suggests that there are both small- and large-scale interventions that can be used to reduce this. Technological advances including prescription monitoring systems and mobile applications have enabled studies to monitor opioid consumption after discharge. Interventions that occur preoperatively, such as patient education and expectation setting regarding postoperative pain management, and interventions that occur postoperatively, such as the implementation of procedure-specific, evidence-based prescribing guidelines and protocols, have been shown to reduce post-discharge opioid consumption. The use of multimodal analgesia and opioid-sparing adjuncts throughout the perioperative period is central to many of these interventions and has essentially become standard of care for management of perioperative pain.
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Affiliation(s)
- Stacey Burns
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Richard Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Center for Perioperative Research, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel Pian
- Department of Biology, Boston University, Boston, MA, USA
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16
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Okoro C, Holt S, Ellison JS, Raskolnikov D, Gore JL. Discharge Opioid Prescription Patterns After Kidney Cancer Surgery. Urology 2021; 153:228-235. [PMID: 33561469 DOI: 10.1016/j.urology.2020.12.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe opioid prescribing patterns for patients undergoing kidney cancer surgery and evaluate associations with medical resource utilization in the postoperative setting. METHODS Linked Surveillance, Epidemiology, and End Results - Medicare data were used to identify patients with kidney cancer who underwent partial or radical nephrectomy (open vs. minimally invasive) from 2007 to 2015. Total dose of discharge opioid prescriptions was quantified into 3 exposure groups based on observed tertiles: 1-199 (low), 200-300 (moderate), and >300 (high) oral morphine milligram equivalents. Associations between exposure groups and patient demographics, clinical factors, and hospital volumes were measured using multivariate logistic regression. Additionally, we identified associations with prior opioid exposure and postoperative medical resource utilization. RESULTS Of 4538 patients meeting inclusion criteria, exposure group distributions were 35% (low), 43.5% (moderate) and 21.6% (high). Over one-third of patients (39.5%) received an opioid prescription within 6 months preceding surgery. High opioid prescriptions were associated with prior exposure, younger age, rural residence and open surgery (P < .001). High opioid prescriptions had increased risk of 90-day readmissions (OR 1.21; CI 1.01-1.45) and long-term opioid exposure (OR 1.34; CI 1.17-1.53). CONCLUSION Prescribing patterns after kidney cancer surgery vary widely. Higher prescribed dose of post-surgical opioids is associated with 90-day hospital readmissions and long-term exposure. Prior opioid exposure conveys a higher risk of medical resource utilization. More judicious opioid prescribing may limit medical resource utilization and help combat the opioid epidemic.
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Affiliation(s)
- Chinonyerem Okoro
- Department of Urology, University of Washington Medical Center, Seattle, WA.
| | - Sarah Holt
- Department of Urology, University of Washington Medical Center, Seattle, WA
| | - Jonathan S Ellison
- Children's Hospital of Wisconsin & Medical College of Wisconsin, Milwaukee, WI
| | - Dima Raskolnikov
- Department of Urology, University of Washington Medical Center, Seattle, WA
| | - John L Gore
- Department of Urology, University of Washington Medical Center, Seattle, WA
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17
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Pain management following robotic-assisted radical prostatectomy: transitioning to an opioid free regimen. J Robot Surg 2021; 15:923-928. [PMID: 33495942 DOI: 10.1007/s11701-021-01191-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
Few studies demonstrate the safety and efficacy of postoperative pain regimens that exclude opioids altogether in patients undergoing robot-assisted radical prostatectomy (RARP). To reduce opioid use, we sought to develop an opioid-free regimen for RARP and determine perioperative outcomes before and after implementation. A retrospective, pre-post-interventional study was performed at a single institution between 8/2018 and 10/2019. An opioid-free pain regimen was developed and instituted on 3/7/2019, and all patients received preoperative counseling regarding pain expectations and management. Postoperative pain score was the primary outcome. Secondary outcomes included postoperative opioid use, length of stay, adverse events and unplanned health encounters within 30 days of discharge. Pearson's chi-squared and Student's t-tests were performed on categorical and continuous variables, respectively. Multivariable analysis was performed to determine risk factors for postoperative opioid use in the opioid-free cohort. A total of 89 patients were included for analysis; consisting of 47 (53%) pre-intervention and 42 (47%) post-intervention patients. Baseline characteristics were similar between groups. A significantly lower proportion of patients in the post-intervention group were administered opioids postoperatively (5% vs 53%, p < 0.01), despite having similar postoperative pain scores (2.69 vs 3.11, p = 0.19) and length of stay (1.0 days vs 1.2 days, p = 0.07). The post-intervention group had a significantly lower rate of opioid discharge prescriptions (14% vs 96%, p < 0.01). The rate of ED visits (12% vs 15%, p = 0.68), pain-related phone calls (17% vs 19%, p = 0.76) or adverse events (19% vs 13%, p = 0.42) were similar between groups. Among the opioid-free group, older patients were less likely to be administered postoperative opioids (OR 0.84, p = 0.046). A structured opioid-free pain regimen following RARP is non-inferior compared to traditional opioid-based standard of care. Adoption of similar regimens can help address the ongoing opioid epidemic in the United States and future work is needed to apply these principles broadly.
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18
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Sawczyn G, Lenfant L, Aminsharifi A, Kim S, Kaouk J. Predictive factors for opioid-free management after robotic radical prostatectomy: the value of the SP® robotic platform. Minerva Urol Nephrol 2020; 73:591-599. [PMID: 33256359 DOI: 10.23736/s2724-6051.20.04038-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to evaluate perioperative factors associated with opioid-free management after robotic radical prostatectomy in a single institution. METHODS From January 2019 to January 2020, data from patients who underwent robotic radical prostatectomy was retrospectively entered in a preapproved IRB database. Data were analyzed according to the postoperative opioid administration in hospital and/or after discharge. Robotic radical prostatectomy was performed using either the standard multi-port Da Vinci Si robotic platform with a transperitoneal approach (MP-RALP) or the novel DaVinci SP® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) with an extraperitoneal approach (SP-EPP). Patients undergoing minimally invasive surgery were included in the "enhanced recovery after surgery" (ERAS) protocol regardless of the surgery approach. RESULTS During the study period, 210 patients matched the selection criteria. Of those, 158(75%) patients received opioids during the hospital stay or after discharge and 52(25%) patients never received opioids. SP-EPP surgical approach and shorter LOS were predictors of never receiving opioids (Odds Ratio [OR]=4.97, (95% CI 1.81-14.77, P=0.002 and OR=0.56, CI 95% 0.35-0.86, P=0.011, respectively). SP-EPP surgical approach was increasing the odds of remaining opioid free whether in-hospital or after discharge (OR= 11.97, 95% CI 4.8-32, P<0.0001 and OR=11.6, 95% CI 4.6-31, P<0.0001, respectively). Finally, a high BMI increased the odds of receiving opioid in hospital or after discharge (OR=0.89, 95% CI 0.82-0.96, P=0.003 and OR=0.89, 95% CI 0.82-0.96, P=0.002, respectively). CONCLUSIONS In this series, after robotic radical prostatectomy the use of a less invasive approach (SP-EPP), a shorter LOS and a lower BMI, were predictive of opioid-free status.
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Affiliation(s)
- Guilherme Sawczyn
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Louis Lenfant
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Unit of Predictive Onco-urology, Department of Urology, GRC N. 5, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Alireza Aminsharifi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soodong Kim
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA -
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19
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Srivastava A, Cort C, Elsamra SE. EDITORIAL COMMENT. Urology 2020; 146:65. [PMID: 33272442 DOI: 10.1016/j.urology.2020.08.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Arnav Srivastava
- Department of Surgery, Division of Urology, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Christian Cort
- Department of Surgery, Division of Urology, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Sammy E Elsamra
- Department of Surgery, Division of Urology, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
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20
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Enikeev D, Taratkin M, Lavrinenko N, Panferov A, Singla N. Re: Welk, et al., an opioid prescription for men undergoing minor urologic surgery is associated with an increased risk of new persistent opioid use. Transl Androl Urol 2020; 9:2299-2301. [PMID: 33209699 PMCID: PMC7658151 DOI: 10.21037/tau-20-884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Nikolai Lavrinenko
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | | | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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21
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Serrell EC, Greenberg CC, Borza T. Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic. Cancer 2020; 127:184-187. [PMID: 33002194 DOI: 10.1002/cncr.33199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Emily C Serrell
- Department of Urology, University of Wisconsin, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
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22
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Ansari B, Tote KM, Rosenberg ES, Martin EG. A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018. Public Health Rep 2020; 135:100S-127S. [PMID: 32735190 PMCID: PMC7407056 DOI: 10.1177/0033354920922975] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies. METHODS We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings. RESULTS The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed. CONCLUSIONS Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.
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Affiliation(s)
- Bahareh Ansari
- Department of Information Science, University at Albany–State University of New York, Albany, NY, USA
| | - Katherine M. Tote
- Department of Epidemiology and Biostatistics, University at Albany–State University of New York, Albany, NY, USA
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Eli S. Rosenberg
- Department of Epidemiology and Biostatistics, University at Albany–State University of New York, Albany, NY, USA
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Erika G. Martin
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
- Department of Public Administration and Policy, University at Albany–State University of New York, Albany, NY, USA
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23
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Huang MM, Patel HD, Su ZT, Pavlovich CP, Partin AW, Pierorazio PM, Allaf ME. A prospective comparative study of routine versus deferred pelvic drain placement after radical prostatectomy: impact on complications and opioid use. World J Urol 2020; 39:1845-1851. [PMID: 32929627 DOI: 10.1007/s00345-020-03439-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To evaluate the association of post-RP drain placement with post-operative complications and opioid use at a high-volume institution. METHODS A prospective, comparative cohort study of patients undergoing robot-assisted or open RP was conducted. Patients for two surgeons did not routinely receive pelvic drains ("No Drain" arm), while the remainder routinely placed drains ("Drain" arm). Outcomes were evaluated at 30 days including Clavien-Dindo complications and opioid use. Intention-to-treat primary analysis and additional secondary analyses were performed using appropriate statistical tests and logistic regression. RESULTS Of 498 total patients, 144 (28.9%) were in the No Drain arm (all robot-assisted) and 354 (71.1%) in the Drain arm. In the No Drain arm, 19 (13.2%) intraoperatively were chosen to receive drains. There was no difference in overall or major (Clavien ≥ 3) complications between groups (p = 0.2 and 0.4, respectively). Drain deferral did not predict complications on multivariable analysis adjusted for age, BMI, comorbidities, clinical risk, surgical approach, operating time, lymphadenectomy, and number of nodes removed [OR 0.61, 95% CI 0.34-1.11, p = 0.10]; nor did it predict symptomatic fluid collection, adjusting for lymphadenectomy and nodes removed [OR 1.14, 95% CI 0.43-3.60, p = 0.8]. Drain deferral did not decrease opioid use (p = 0.5). Per protocol analysis and restriction to robot-assisted cases demonstrated similar results. CONCLUSION There was no difference in adverse events, complications, symptomatic collections, or opioid use with deferral of routine drain placement after RP. Experienced surgeons may safely defer drain placement in the majority of robot-assisted RP cases.
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Affiliation(s)
- Mitchell M Huang
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA.
| | - Hiten D Patel
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA
| | - Zhuo T Su
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA
| | - Christian P Pavlovich
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA
| | - Alan W Partin
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA
| | - Phillip M Pierorazio
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA
| | - Mohamad E Allaf
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA
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Huang MM, Patel HD, Wainger JJ, Su ZT, Becker REN, Han M, Pierorazio PM, Allaf ME. Comparison of Perioperative and Pathologic Outcomes Between Single-port and Standard Robot-assisted Radical Prostatectomy: An Analysis of a High-volume Center and the Pooled World Experience. Urology 2020; 147:223-229. [PMID: 32896583 DOI: 10.1016/j.urology.2020.08.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/16/2020] [Accepted: 08/26/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To perform an early comparative study of outcomes between single-port and robot-assisted laparoscopic radical prostatectomy (SP-RALRP) and standard RALRP at our institution and pooled analysis of series to date. PATIENTS AND METHODS Patients with organ-confined prostate cancer undergoing SP-RALRP at a high-volume institution were identified retrospectively along with reported SP-RALRP series to date. Data were compared to a contemporary prospective cohort of men undergoing standard RALRP. Patient demographics, perioperative and postoperative data, and complications categorized by the Clavien-Dindo system were compared for the institutional and pooled SP-RALRP cohorts to standard RALRP. RESULTS A total of 208 SP-RALRP cases were identified (26 from our institution) and compared to 376 standard RALRP cases. In the institutional analysis, there was no difference in operative time, length of stay, overall complications (15.4% vs 17.3%, P= 1.0), major (Clavien ≥III) complications (3.8% vs 3.7%, P = .6), inpatient opioid use, or patient-reported pain scores; median estimated blood loss (100 mL vs 150 mL, P = .02) and number of lymph nodes removed (5.5 vs 9, P = .002) were lower for SP-RALRP. In the pooled analysis, 208 patients receiving SP-RALRP had similar estimated blood loss and complication rates but fewer lymph nodes removed (P = .02) and marginally longer operating time (+16 minutes, P = .01) compared to standard RALRP. The difference in rate of positive surgical margins was not statistically significant (31.3% vs 24.5%, P = .08). CONCLUSION Based on an early experience with SP-RALRP at a high-volume center and a pooled analysis of SP series to date, perioperative and pathologic outcomes appear nearly equivalent compared to standard RALRP.
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Affiliation(s)
- Mitchell M Huang
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Hiten D Patel
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julia J Wainger
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zhuo T Su
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell E N Becker
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Misop Han
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohamad E Allaf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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Huang MM, Su ZT, Becker REN, Pavlovich CP, Partin AW, Allaf ME, Patel HD. Complications after open and robot-assisted radical prostatectomy and association with postoperative opioid use: an analysis of data from the PREVENTER trial. BJU Int 2020; 127:190-197. [PMID: 32654363 DOI: 10.1111/bju.15172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate perioperative complications for open radical prostatectomy (ORP) and robot-assisted RP (RARP) for patients enrolled in the PREvention of VENous ThromboEmbolism Following Radical Prostatectomy (PREVENTER; ClinicalTrials.gov Identifier: NCT03006562) trial, to determine predictors and impact on opioid consumption. PATIENTS AND METHODS A prospective cohort of 500 patients undergoing ORP and RARP was followed to determine rates of complications and opioid use. Complications were classified 30 days after RP using the Clavien-Dindo system. Patient characteristics and outcomes were compared using appropriate statistical tests. Logistic and linear regressions were performed to identify predictors of complications and evaluate the relationship between complications and postoperative opioid use. RESULTS A total of 124 (24.8%) men underwent ORP and 376 (75.2%) RARP, with 418 (83.6%) receiving pelvic lymph node dissection (PLND). While 83 patients (16.6%) had complications, only 19 (3.8%) were major (Clavien-Dindo Grade ≥III), with no differences by surgical approach. PLND (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.25-8.71; P = 0.03) and Stage pT3b (OR 2.76, 95% CI 1.23-6.00;P = 0.01) were the only predictors of complications after controlling for potential confounders. Patients who had complications had greater inpatient (P = 0.02) and outpatient (P = 0.005) opioid use, which persisted after controlling for patient-reported pain, attending surgeon variation, surgical approach, and undergoing PLND (inpatient β:77.2, 95% CI 17.9-136.5,P = 0.03; and outpatient β:21.9, 95% CI 4.7-39.1,P = 0.01). CONCLUSION In an analysis of prospectively collected data, overall and major complications rates did not differ by surgical approach. Patients receiving PLND and with Stage pT3b disease had more complications. Complications were independently associated with higher inpatient and outpatient postoperative opioid use.
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Affiliation(s)
- Mitchell M Huang
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zhuo T Su
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Russell E N Becker
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian P Pavlovich
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alan W Partin
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohamad E Allaf
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hiten D Patel
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Patients' Experience With Opioid Pain Medication After Discharge From Surgery: A Mixed-Methods Study. J Surg Res 2020; 256:328-337. [PMID: 32731094 DOI: 10.1016/j.jss.2020.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/19/2020] [Accepted: 06/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Decreasing the number of prescription opioids has been a leading strategy in combating the opioid epidemic. In Vermont, statewide and institutional policies have affected prescribing practices, resulting in a 40% decrease in postoperative opioid prescribing. The optimal approach to postoperative opioid prescribing remains unknown. In this study, we describe patients' experience with pain control 1 wk after discharge from surgery. MATERIALS AND METHODS We assessed patients' experience using a telephone questionnaire, 1-wk after discharge after undergoing common surgical procedures between 2017 and 2019 at an academic medical center (n = 1027). Scaled responses regarding pain control, opioids prescribed, and opioids used (response rate 96%) were analyzed using a mixed-methods approach; open-ended patient responses to questions regarding whether the number of opioids prescribed was "correct" were analyzed using qualitative content analysis. RESULTS One week after discharge, 96% of patients reported that their pain was well controlled. When asked whether they received the correct number of opioid pills postoperatively, qualitative analysis of patient responses yielded the following six themes: (1) I had more than I needed, but not more than I wanted; (2) Rationed medication; (3) Medication was not effective; (4) Caution regarding risks of opioids; (5) Awareness of the public health concerns; and (6) Used opioids from a prior prescription. CONCLUSIONS Patient-reported pain control after common surgical procedures was excellent. However, patients are supportive of receiving more pain medications than they actually use, and they fear that further restrictions may prevent them or others from managing pain adequately. Understanding the patients' perspective is important for surgical education and improving discharge protocols.
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