Opioids crisis: Urologists are part of the problem-and solution

If you ask urologist Benjamin J. Davies, MD, about opioid prescribing in the specialty, he’ll say: “The vast majority of patients we operate on do not need narcotics at all. None.”

That’s a big practice shift for Dr. Davies, who not long ago would prescribe 20, 30, or more oxycodone or other narcotic pills to urologic surgery patients. It was the norm, he said.

“We didn’t have any particular data per procedure on how much to give. We kind of eyeballed it. Bigger procedures got bigger prescriptions,” said Dr. Davies, associate professor of urology at the University of Pittsburgh School Of Medicine. “We just wanted to make sure our patients didn’t have pain.”

Strong evidence has emerged in recent years suggesting opioid prescribers, including well-meaning urologists, have helped to fuel a national crisis and opioid addiction epidemic. Every day, more than 115 people in this country die because they’ve overdosed on opioids, including prescription pain relievers, according to the National Institute on Drug Abuse.

The current opioid crisis is the third opioid epidemic in the history of the U.S., according to urologist Francis J. McGovern, MD, assistant clinical professor of surgery at Harvard Medical School, Massachusetts General Hospital, Boston.

“This most recent opioid epidemic began in the late 1990s and parallels the initiation of pain as the fifth vital sign, which is the result of unfortunate misguided bureaucracy, with physicians being mandated to have pain scales in every office visit,” Dr. McGovern said.

Prescription opioid sales jumped fourfold from 1999 to 2008, paralleling a fourfold increase in deaths from prescription opioids in the same period, according to a recently published study by Dr. Davies and colleagues (Urology Aug. 24, 2018 [Epub ahead of print]).

“Urologists and all physicians have a role and responsibility to try and get this epidemic under control,” said Dr. McGovern, who has presented on the issue of opioid prescribing at AUA annual meetings.

Next:Overprescribing is realOverprescribing is real

Urologists commonly overprescribed postoperative narcotics after urologic surgery, researchers reported in the Journal of Urology (2011; 185:551–5). Sixty-seven percent of patients who had undergone urologic surgery at the University of Utah had leftover opioids, including hydrocodone and oxycodone, after their initial prescriptions. More than 90% received no instructions for how to safety dispose of unused meds, the study authors found.

Read: Never enough time? Try putting your phone down

In the recent Urology study, Dr. Davies and colleagues examined opioid prescription use in 155 opioid-naïve patients who had robotic prostatectomy, robotic partial nephrectomy, open prostatectomy, or open partial nephrectomy from January 2017 to May 2017. Researchers surveyed patients 3 to 4 weeks postoperatively asking how many of the prescribed drugs were used.

They found opioid prescribing far exceeded use from 1.9- to 6.8-fold for the procedures studied.

“Overall, a total of 4,065 oxycodone-equivalents were prescribed during this study and 60% of pills prescribed went unused. This resulted in 2,622 excess pills in the community,” the authors wrote.

Dr. Davies said even he was shocked at patients’ low usage of narcotics following robotic nephrectomy and prostatectomy.

“We averaged eight pills. And when you actually talk to patients, many people took none. Even among the ones that did take a good amount, many said they didn’t need to but they took them because they had the pills,” Dr. Davies said.

There is great variation in opioid prescribing patterns among urologists, according to Greg Auffenberg, MD, MS, who conducted research on opioid prescribing in urology while at the University of Michigan. Today, he’s assistant professor of urology at Northwestern University, Chicago.

“We found an unbelievable heterogeneity across providers-in some cases a 20-fold variation-for how much opioid prescriptions patients were filling after similar surgical events,” said Dr. Auffenberg, who was among the authors of an AUA position statement on opioid use.

Other research points to notable addiction risks among even opioid-naïve patients who take those meds, he said.

Also see: Adherence to surveillance high in large urology practices

“Research out of Dartmouth recently showed among patients taking no opioids before surgery, somewhere between 5% and 7% were still taking opioids 3 to 6 months after surgery, which is beyond when they should still have surgical pain,” Dr. Auffenberg said.

Next:Solutions to a crisisSolutions to a crisis

Mass General Hospital is attacking opioid overprescribing with clinical pathways that focus on use of alternative pain management options, multidisciplinary collaboration, and patient education, according to Dr. McGovern.

Read: Phase III RCC trial challenges current standard of care

Preoperatively, surgeons can use non-narcotic medications, such as celecoxib (Celebrex), which has been shown to lower patients’ postoperative need for opioids, Dr. McGovern said.

Urologists should collaborate with anesthesia colleagues to utilize nonopioid alternatives for pain management during and after surgery when possible. Utilization of blocks, including regional or local anesthetics, can greatly reduce surgical patients’ narcotic needs, he said.

“For example, patients having major intra-abdominal surgery, such as operating on a large kidney tumor with major debulking of lymph nodes or possible invasion of the vena cava; these patients would be best served by placement of an epidural or regional anesthesia in addition to general anesthesia that they will receive intraoperatively,” Dr. McGovern said. “Postoperatively, the epidural can be utilized to give them a regional block.”

Mass General surgeons first try local blocks, including incisional blocking, which Dr. McGovern said are extremely helpful in reducing the postoperative opioid use.

Decreasing opioid use during and immediately after surgery offers many potential benefits, including decreased risk of readmission, according to Dr. McGovern. He said a soon-to-be-published study by Massachusetts General researchers found the number of opioids consumed even in the first 24 hours perioperatively can predict whether a patient will likely be readmitted to the hospital. In essence, high opioid use is linked with more likely hospital readmission.

“In the United States, the most common reason for a postoperative surgical patient from all types of surgery to re-present to an emergency room is with the chief complaint of nausea and vomiting,” Dr. McGovern said. “Opioid-related adverse events include respiratory suppression, nausea, vomiting, urinary retention, difficulty voiding, cognitive impairment, constipation. In rare cases, respiratory suppression can be severe enough that it leads to death from respiratory arrest.”

There are still other reasons urologists and other clinicians should think twice about prescribing opioids. One is that taking high doses of opioids intraoperatively and immediately postoperatively can create a hyperalgesia-like syndrome where patients even weeks later are more sensitive to pain, according to Dr. McGovern.

Like Dr. Davies, Dr. McGovern studied his own approach to surgery to optimize outcomes and potentially lower opioid prescribing.

“I have now done over 4,000 radical prostatectomies,” Dr. McGovern said. “In the first 2,000, we gave patients a [patient-controlled analgesia] or low-dose continuous morphine pump. Those patients had much longer hospitalization and greater readmission rates. Now with preemptive Tylenol and Celebrex and giving a rectus sheath block, numbing the rectus abdominis, patients go home on post-op day one. The readmission rate is under 1%. Complication rates are also considerably reduced.”

Dr. McGovern lets patients know he’ll prescribe some opioids to manage acute, significant pain if the patient absolutely needs them. But, he said, by the time he educates patients about what to expect and the potential consequences of opioid use, many become partners in the goal to go without.

He and colleagues make it a point to educate floor staff, nursing, nurse practitioners, and physician assistants about the goal to reduce opioid use.

“With this, we have significantly reduced our need for opioids post-op,” Dr. McGovern said. “The amount that we’re sending patients home with now is down to about 25% of the number of pills that we used to send patients home with.”

At Stanford Health Care in Stanford, CA, a similar strategy has led to a 46% decrease in opioid use in patients who underwent a range of urologic cancer surgeries without increasing their pain or anxiety, researchers reported last month at the American Society of Clinical Oncology’s Quality Care Symposium in Phoenix. The group’s two-pronged approach involves care pathways for post-op pain control using non-opioid medications as first-line therapies and a change in postoperative patient conversations in which nurses, rather than routinely asking patients if they want opioids, discuss current non-opioid medications patients are receiving for pain and ask whether those medications are sufficient.

Also see: What has been your experience with ERAS pathways?

“With the new approach, opioids were never withheld, but they were no longer the automatic default for patients and providers,” said lead author Kerri Stevenson, MN, NP-C, a nurse practitioner at Stanford.

Next:No to narcoticsNo to narcotics

Dr. Davies said that none of his robotic surgery patients had received narcotics in the 6 weeks prior to his September 2018 interview with Urology Times. In the past, he’d write prescriptions for an average 25 opioid pills for patients about to undergo partial nephrectomy or robotic prostatectomy, he said.

Read:Adequate translation services crucial; here’s why

“I haven’t gotten a single patient complaint. And I don’t think I’m going to,” Dr. Davies said. “As long as my patients are preoperatively warned, they’re told to manage their expectations correctly, and as long as their pain is treated correctly, the patients will be fine. Patients can be treated with Motrin and Tylenol just fine. They don’t need narcotics.”

Dr. McGovern said he enjoys practice more because his patient outcomes are better with less opioid use. They recover faster and their recovery is safer, and they’re less likely to call the office at night and on weekends during the perioperative recovery, he said.

“Since doing these blocks, I have not needed to refill anyone’s pain medicine after their first discharge prescription from the hospital,” Dr. McGovern said. “So, I would caution all urologic surgeons to be very careful of refilling opioid pain prescriptions postoperatively after one week or so of surgery. If they do need to refill, then they should consider referring patients to a pain clinic where pain specialists evaluate patients for nonopioid solutions to their pain.”

Opioids might be an appropriate drug for cancer pain but not for acute post-surgical pain, but they’re not worth the consequence of potential addiction in surgical and other urologic patients, according to Dr. Davies, whose best friend died of a heroin overdose in 1999, when Dr. Davies was a fourth-year medical resident. He wrote about the experience in the article, “I lost my best friend to opioids. Yet, as a surgeon I overprescribed them,” published earlier this year in Forbes.

Also see: Shared decision-making presents opportunity for APPs

“I do about 400 or 500 major cases a year,” Dr. Davies said. “Can you imagine how many cases in my lifetime I’ve addicted? It’s a pretty stark reality. I have no intention of doing that any further.”

Next:Learn more at AUA opioid stewardship summit

Learn more at AUA opioid stewardship summit

Urologists who want to learn more about opioid stewardship should consider attending the AUA 2018 Quality Improvement Summit at AUA headquarters in Linthicum, MD, Saturday, Dec. 8, 2018. They can sign up for the event focusing on opioid stewardship in the specialty at bit.ly/Opioid-summit.

Greg Auffenberg, MD, MS, the summit’s co-chair, said the day-long event will feature about a dozen speakers from multiple disciplines, including surgical fields, pain medicine, addiction medicine, complementary alternative medicine, and public policy.

Read: Post-PCa symptom program found feasible

“We’re encouraging urologists to attend,” Dr. Auffenberg said. “It’s designed to be an interactive conference where people come and share their perspectives.”

The AUA will post video content from the summit in the weeks following the event and plans and plans to disseminate educational content for urologists and patients from the meeting, he said.