Presentation Authors: Daniel Greenberg*, Jessica Kee, Kerri Stevenson, Elizna Van Zyl, Anisia Dugala, Kris Prado, Harcharan Gill, Eila Skinner, Jay Shah, Stanford, CA
Introduction: Radical cystectomy (RC) is the gold standard treatment for muscle-invasive bladder cancer. This procedure carries significant morbidity, requires 5-10 hospital days to recover, and has a 30% readmission rate after discharge. Following RC, patients are often exposed to a prolonged course of opioid medications for acute pain management. Previous studies have shown that 6% of patients become newly addicted to opioid medications while in the hospital. To address this risk, we implemented a Reduced Opioid Utilization (ROU) protocol aimed to decrease opioid exposure after RC surgery.
Methods: We identified causes contributing to excess opioid use and designed a multimodal opioid-sparing pain regimen to create the ROU protocol. Interventions were also aimed at educating patients and healthcare providers on the availability and efficacy of non-opioid medications. We prospectively measured opioid use, calculated as morphine equivalent dose (MED), and pain scores for patients who underwent RC for up to 7 months after implementation of the ROU protocol. We retrospectively compared this data to patients who underwent RC during the 7 months prior to the intervention. Opioid-related adverse drug events (ORADEs), recovery milestones, length of stay, and 90-day complication rates were also compared between cohorts.
Results: 104 patients underwent RC during the study period, 54 (52%) of whose postoperative course followed the ROU protocol. There was no significant difference in age, BMI, comorbidities, or history of previous opioid use between ROU and non-ROU RC patients. ROU patients experienced a statistically significant decrease in opioid exposure in the post-anesthesia care unit (14.8Â±2.9 MED vs 30.5Â±4.4, p < 0.01) and during their inpatient postoperative recovery (85.7Â±21.0 MED vs 352.6Â±34.4 MED, p < 0.001). ROU patients also had a statistically significant decrease in the rate of ORADEs (13% vs 54%, p < 0.001), time to first bowel movement (3.08Â±0.22 days vs 3.78Â±0.24 days, p < 0.05), and time to tolerance of a regular diet (2.48Â±0.20 days vs 3.84Â±0.31 days, p < 0.001). There was no significant difference in 24-, 48-, and 72-hour average pain scores, length of stay, or 90-day complication rates between groups.
Conclusions: The ROU protocol decreased opioid use after RC surgery by 74% without compromising pain control or increasing the rate of complications. This initiative demonstrates the efficacy of non-opioid medications in controlling acute pain, and highlights the role healthcare providers can play to decrease patient exposure to opioids after surgery.