Presentation Authors: Kevin Koo*, Farzana Faisal, Natasha Gupta, Alexa Meyer, Hiten Patel, Anastasia Padilla, Whitney Sharpe, Michael Gorin, Mohit Gupta, Misop Han, Michael Johnson, Christian Pavlovich, Phillip Pierorazio, Mohamad Allaf, Brian Matlaga, Baltimore, MD
Introduction: Opioids are frequently overprescribed after urological surgery. The 2018 AUA position statement on opioid use suggests using the lowest dose and potency to achieve post-operative pain control, but a lack of procedure-specific prescribing guidelines contributes to wide variation in prescribing patterns. This study addresses this gap through an expert panel consensus.
Methods: A 15-member multidisciplinary expert panel included representatives from 5 stakeholder groups (attending urologists, multispecialty fellows, residents, nurse practitioners, and patients). We used a 3-step modified Delphi method to develop consensus recommendations for opioid prescribing after 9 minimally-invasive procedures, encompassing transurethral surgery and laparoscopic and robotic kidney and prostate surgery for benign and malignant disease. Recommendations were made for opioid-naive patients without chronic pain conditions. The panel used oxycodone 5 mg equivalents to define the number of prescribed tablets.
Results: Procedure-specific recommendations were developed for all 9 procedures. The panel agreed that not all patients desire or require opioids after surgery; thus, the minimum recommended number of opioids for all procedures was 0 tablets. The maximum number of opioids varied by procedure, from 0 tablets for 2 of the 9 procedures, to 15 tablets (mean 10.6 tablets). For the majority of procedures, nurses and trainees voted for lower opioid quantities than attending urologists. The panel developed 8 strategies for opioid stewardship: 1) Prescribing is a shared decision with patients, and opioids should not be prescribed to patients who express a preference not to use them; 2) Consider clinical factors affecting a patient's expected response to opioids; 3) Maximize non-opioid agents, including acetaminophen and NSAIDs, for baseline pain control, unless contraindicated; 4) In patients hospitalized after surgery, consider how frequently they have used opioids to achieve adequate pain control, to anticipate post-discharge needs; 5) Query prescription drug monitoring programs where available; 6) Patients should be provided information about safe opioid storage and disposal; 7) Prior to refilling opioids, assess patterns of pain management and consider post-operative complications; 8) Patients with chronic pain may have needs beyond the scope of these recommendations.
Conclusions: Procedure-specific guidelines for prescribing opioids after minimally-invasive surgery may help clinicians align individual prescribing habits with consensus recommendations. These guidelines can aid quality improvement efforts to reduce overprescribing in urology.