Panel issues urology-specific opioid Rx recommendations

Recommendations on opioid prescribing after endourologic and minimally invasive urologic surgery from an expert panel should help urologists align individual prescribing habits with current evidence, reduce opioid overprescribing, and provide a framework for refining patient-centered guidelines for opioid stewardship in urology, said Kevin Koo, MD, MPH, MPhil.

The project to develop recommendations for opioid prescribing was undertaken recognizing evidence that postsurgical prescribing is contributing to the opioid epidemic and showing that a lack of procedure-specific prescribing guidelines underlies wide variation in surgeons’ prescribing patterns.

The recommendations pertain specifically to opioid-naïve patients without chronic pain conditions and define a range of oxycodone 5-mg equivalent tablets considered appropriate for each of 16 procedures. In addition, the panel described eight overarching strategies that are intended to strengthen opioid safety and stewardship.

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“Excess postsurgical prescribing has been implicated in the widespread availability of opioids. Across a broad range of procedures, patients consistently report not needing 70% to 90% of the tablets they were prescribed,” said Dr. Koo, instructor of urology, Johns Hopkins University School of Medicine, Baltimore.

“Considering emerging evidence that opioid overprescribing declines for both targeted procedures and overall when prescribers have guidelines, we aimed to develop procedure-specific recommendations for opioid prescribing after endourological and minimally invasive urological procedures.”

Dr. Koo initially presented the recommendations at the 2019 AUA annual meeting in Chicago, and they were subsequently published in theJournal of Urology (2020; 203:151-8).

The recommendations were developed by a 15-member expert panel representing five stakeholder groups-attending urologists, multispecialty fellows, residents, nurse practitioners, and patients. Using a three-step modified Delphi method, specific recommendations for opioid prescribing were outlined for the 16 procedures that encompass lower tract endoscopy, upper tract endoscopy, and laparoscopic and robotic kidney and prostate surgeries for benign and malignant disease.

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The panel agreed that no opioids should be prescribed for patients who undergo diagnostic cystoscopy, transurethral resection of bladder tumor, or diagnostic ureteroscopy without stent placement. In addition, it was the panel’s consensus that non-opioid pain management is a potentially appropriate option for all of the other procedures, so the minimum number of recommended opioids was also zero tablets.

“While there have been reports of narcotic-free urological surgery, such as ureteroscopy, the panel agreed that using zero narcotics is not necessarily a categorical goal. Instead, opioid use should be tailored to each patient according to preferences and expected needs using shared decision-making,” said Dr. Koo.

A maximum of five oxycodone 5-mg tablets was recommended for patients who had transurethral resection of the prostate or ureteroscopy or lithotripsy without stent placement, and a maximum of 10 tablets was recommended for those who had ureteroscopy or lithotripsy with a stent; urgent ureteral stent placement; or percutaneous nephrolithotomy with a stent, with or without nephrostomy. A maximum of 15 tablets was recommended for all of the laparoscopic or robotic procedures, including radical and partial nephrectomy and radical and simple prostatectomy.

Dr. Koo noted that the recommendations are consistent with emerging procedure-specific observational data.

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“A prospective study at Johns Hopkins that included 205 patients undergoing open and robotic prostatectomy found that 15 tablets of oxycodone satisfied the post-discharge needs of 84% of patients.”

The strategies for opioid stewardship encourage that postsurgical opioid prescribing should be approached through shared decision-making.

“Patients’ preferences and concerns should be incorporated when surgeons decide whether and how much opioids to prescribe, and opioids should not be prescribed to patients who specifically express a preference not to use them,” Dr. Koo said.

To help prevent unused opioids from becoming available for misuse, the eight strategies include that prescribers should approach postsurgical opioid prescribing as a shared decision with patients and provide information to patients about safe storage and disposal of unused opioids. Other strategies encourage prescribers to consider clinical factors that may affect a patient’s expected response to opioids, maximize routine use of non-opioid agents unless contraindicated, consider pre-discharge opioid requirements to anticipate post-discharge needs, query prescription drug monitoring programs where available, assess patients’ patterns of medication use and sources of pain prior to refilling opioids, and consider the additional needs of patients with chronic pain or complex pain syndromes.