Dataset Information

Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery.

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.

SUBMITTER: Mian BM

PROVIDER: S-EPMC9909575 | biostudies-literature | 2023 Apr

REPOSITORIES: biostudies-literature

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Publications

Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery.

Mian Badar M BM Singh Zorawar Z Carnes Kevin K Lorenz Leanne L Feustel Paul P Kaufman Ronald P RP Avulova Svetlana S Bernstein Adrien A Cangero Theodore T Fisher Hugh A G HAG

JAMA surgery 20230401 4

<h4>Importance</h4>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.<h4>Objective</h4>To assess a protocol for eliminating postdischarge opioid prescriptions after major urologic cancer surgery.<h4>Design, setting, and participants</h4>This cohort study of the no opioid prescriptions at discharge after surgery (NOPIOID ...[more]

PMID: 36753170

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Project description:ImportanceThe increased use of prescription opioid medications has contributed to an epidemic of sustained opioid use, misuse, and addiction. Adults of working age are thought to be at greatest risk for prescription opioid dependence.ObjectiveTo develop a risk score (the Stopping Opioids After Surgery score) for sustained prescription opioid use after surgery in a working-age population using readily available clinical information.Design, setting, and participantsIn this case-control study, claims from TRICARE (the insurance program of the US Department of Defense) for working-age adult (age 18-64 years) patients undergoing 1 of 10 common surgical procedures from October 1, 2005, to September 30, 2014, were queried. A logistic regression model was used to identify variables associated with sustained prescription opioid use. The point estimate for each variable in the risk score was determined by its β coefficient in the model. The risk score for each patient represented the summed point totals, ranging from 0 to 100, with a lower score indicating lower risk of sustained prescription opioid use. Data were analyzed from September 25, 2018, to February 5, 2019.ExposuresExposures were age; race; sex; marital status; socioeconomic status; discharge disposition; procedure intensity; length of stay; intensive care unit admission; comorbid diabetes, liver disease, renal disease, malignancy, depression, or anxiety; and prior opioid use status.Main outcomes and measuresThe primary outcome was sustained prescription opioid use, defined as uninterrupted use for 6 months following surgery. A risk score for each patient was calculated and then used as a predictor of sustained opioid use after surgical intervention. The area under the curve and the Brier score were used to determine the accuracy of the scoring system and the Hosmer-Lemeshow goodness-of-fit test was used to evaluate model calibration.ResultsOf 86 356 patients in the analysis (48 827 [56.5%] male; mean [SD] age, 46.5 [14.5] years), 6365 (7.4%) met criteria for sustained prescription opioid use. The sample used for model generation consisted of 64 767 patients, while the validation sample had 21 589 patients. Prior opioid exposure was the factor most strongly associated with sustained opioid use (odds ratio, 13.00; 95% CI, 11.87-14.23). The group with the lowest scores (<31) had a mean (SD) 4.1% (2.5%) risk of sustained opioid use; those with intermediate scores (31-50) had a mean (SD) risk of 14.9% (6.3%); and those with the highest scores (>50) had a mean (SD) risk of 35.8% (3.6%).Conclusions and relevanceThis study developed an intuitive and accessible opioid risk assessment applicable to the care of working-age patients following surgery. This tool is scalable to clinical practice and can potentially be incorporated into electronic medical record platforms to enable automated calculation and clinical alerts that are generated in real time.

Project description:IntroductionFilling an opioid prescription after a minor urologic procedure increases patient risk of overdose and misuse. Strategies to reduce the number of opioids reaching the community are critical. This study evaluates opioid use after minor urologic procedures at a Canadian academic center and guides future prescribing recommendations.MethodsWe prospectively evaluated patients over 18 years old undergoing minor urologic procedures (penile, scrotal, urethral, etc.) from September 2020 to May 2022. Consenting participants were given a pain diary and postoperative pain questionnaire. Patients on chronic pain medications or those who had major surgery within six months were excluded. Response rate, pain on visual analog scale, pain control satisfaction, quantity of opioids prescribed, and consumption of opioid and non-opioid medication were collected and analyzed.ResultsNinety-five patients met the inclusion criteria. The mean age was 61.7 years (range 20- 87) and 96% of patients identified as male. The response rate for the opioid diary and pain questionnaire was 57%. Forty-two patients (78%) were offered an opioid prescription following their surgery, but only 12 of those patients (22%) filled and consumed any opioids analgesics. Forty-two patients (78%) used no postoperative opioids, and the mean oral morphine equivalents (OME) consumed was 5.87 (standard deviation 16.7). There was a total of 259 OME unused from post-procedure prescriptions. The mean overall pain score for patients who did and did not fill opioid prescriptions were 3.18/10 and 1.79/10 (p<0.01), respectively, with mean overall pain management satisfaction score of 8.63/10 and 8.58/10 (p=0.94), respectively.ConclusionsMost patients undergoing minor urologic procedures do not require opioids to manage postoperative pain. Based on our data, we suggest that a prescription for 39 OME would adequately treat postoperative pain in 95% of patients undergoing minor urologic procedures. Education around pain management with non-narcotic modalities is imperative, and practice changes are warranted to address the opioid crisis within our specialty.

Project description:BackgroundEmergency departments increasingly use nonopioid analgesics to manage acute pain and minimize opioid-related harms. Urgent care centers are expanding to lower costs and provide efficient access to healthcare. General internists increasingly work in these acute care settings. Much is known about opioid prescribing in the primary care, inpatient, and emergency department setting. Little is known about opioid prescribing in the urgent care setting and associated outcomes.ObjectivesTo assess the association between in-clinic opioid administration and opioid receipt at clinic discharge and on progression to chronic opioid use among urgent care patients.DesignRetrospective cohort study.ParticipantsPatients, 20 years or older and not on opioid medications, who presented for care to an urgent care clinic within a safety-net healthcare system from June 1, 2016, to April 30, 2019.Main measuresWe examined the association between the in-clinic administration of oral or intravenous opioids and opioid receipt at clinic discharge. We also examined the association between in-clinic opioid administration and progression to chronic opioid use after six months.Key resultsThe study sample included 34,978 patients, of which 13.8% (n = 4842) received in-clinic opioids and 86.2% (n = 30,136) did not receive in-clinic opioids. After adjusting for age, gender, race/ethnicity, insurance, and pain diagnosis, patients who received in-clinic opioids were more likely to receive opioids at discharge compared to patients who did not receive in-clinic opioids (aOR = 12.30, 95% CI 11.44-13.23). Among a selected cohort of patients, in-clinic opioid administration was associated with progression to chronic opioid use (aOR = 2.12, 95% CI 1.66-2.71).ConclusionsIn-clinic opioid administration was strongly associated with opioid receipt at discharge and progression to chronic opioid use. Increased use of nonopioid analgesics in urgent care could likely reduce this association and limit opioids available for diversion, overdose, and death.

Dataset Information

Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery.

Importance

Objective

Design, setting, and participants

Interventions

Main outcomes and measures

Results

Conclusions and relevance

Publications

Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery.

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