Best Practices & Benign Disease
Introduction & Objective : Opioid pain medications are overprescribed, but little data is available to appropriately tailor post-discharge opioid prescriptions after surgery. Prior studies are retrospective and based on incomplete responses (<50%) to questionnaires with small sample sizes for any particular surgery. The objective of our study was to prospectively measure post-discharge opioid prescribing, use, and predictors for consecutive patients after radical prostatectomy to establish a reference value and compare open and robotic surgery.
Methods : A prospective, non-randomized, pre-post cohort study of patients undergoing radical prostatectomy for prostate cancer (2017-2018) as part of the Opioid Reduction Intervention for Open, Laparoscopic, and Endoscopic Surgery (ORIOLES) was conducted. The primary outcome was total oral morphine equivalents (OMEQ) used after surgery with a reference value set to meet the needs of >80% of patients. Surgical approach and predictors of use were assessed via multivariable linear regression and mixed effects models. A prospective, post-intervention cohort was then evaluated after implementation of a discharge sheet, nursing education, and standardized prescribing based on the reference value.
Results : All 205 patients (100%) completed follow-up in the pre-intervention cohort. In units of OMEQ, a median of 225mg was actually prescribed and 22.5mg used (compared to a provider-recommended reference value of 180mg). There was no difference by surgical approach or among patients with a history of a pain-related diagnosis. Overall, 77% of post-discharge opioid medication was unused with 84% of patients requiring ≤112.5mg OMEQ. Only 9.3% of patients appropriately disposed of leftover medication. About 5% reported continued incisional pain due to surgery at 30-days but none required continued opioid medication use. Prescribing more opioids was independently associated with greater opioid use in adjusted models. In the post-intervention cohort (N=87), OMEQ prescribed was reduced by 45.5% (mean 226.5mg to 123.4mg) and use by 21.5% (mean 52.5mg to 41.2mg) with a slight increase in disposal (9.3% to 16.9%). Only 5 (5.7%) patients required additional opioid medication.
Conclusions : Opioid pain medications are overprescribed relative to actual use by patients after radical prostatectomy with more opioids used when a greater quantify is prescribed. An appropriate baseline reference value for prescriptions after radical prostatectomy is 112.5mg OMEQ. The ORIOLES initiative demonstrated a reduction in prescribing and use after implentation of an evidence-based intervention.