Post-procedure opioid Rx may be unnecessary

Routine prescribing of opioids may not be necessary for effective pain management after outpatient urologic procedures, but the practice may contribute to the opioid epidemic.

Those are the findings of a prospective randomized study presented by researchers from Case Western Reserve University, Cleveland at the AUA annual meeting in Chicago. The study randomized patients to receive a prescription for 30 oxycodone 5-mg tablets or 20 ketorolac 10-mg tablets. Patients were instructed to take oxycodone, 5-10 mg every 4 hours as needed for up to 5 days, or ketorolac, 10 mg every 6 hours as needed for up to 5 days, and they were given oral and written instructions for disposing any unused medication.

Information was collected from patients via telephone surveys conducted 1 week after the procedure. Findings from an interim analysis that included data from 91 patients showed that the prescription fill rate was higher in the oxycodone group than in the ketorolac group (84% vs. 60%). In both groups, the majority of medication was not used, although the mean number of pills taken was significantly higher for oxycodone than ketorolac (7.4 vs. 3.1; p=.0005).

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Data on pain severity assessed using a validated instrument (Indiana Polyclinic Combined Pain scale) indicated that ketorolac was non-inferior to oxycodone for providing pain relief. In addition, the study found that overall, only 9% of patients who filled their prescriptions disposed of their medications appropriately, and the percentage of patients who failed to do so was significantly higher in the oxycodone group, where 71% of patients kept their unused pills, reported Kirtishri Mishra, MD, of Case Western Reserve University.

“Statistics about the growing burdens of opioid addiction, including data showing rising rates of overdose-related deaths and of infants born with neonatal abstinence syndrome, are alarming, and indiscriminate physician prescribing of narcotics for pain management is clearly contributing to these problems,” said Dr. Mishra, who worked on the study with Christopher M. Gonzalez, MD, MBA, and colleagues.

“Previous retrospective studies have shown that a large percentage of patients who undergo surgical procedures do not fill their prescriptions for analgesics or do not use the medications if they do. Our prospective study is part of a longer range project to provide a higher level of evidence about usage of opioids after outpatient urologic procedures and to offer solutions that may decrease opioid prescribing and its related problems.”

Patients were eligible to participate in the study if they were age 18 years or older, underwent an uncomplicated outpatient urologic procedure, had a glomerular filtration rate >40 mL/min/1.73 m², and had no history of problems related to opioid use. There were no significant differences between the oxycodone and ketorolac groups in demographic characteristics, procedure types, or current alcohol use.

Next: URS accounts for half of proceduresOverall, ureteroscopy accounted for about 50% of the procedures and transurethral resection of the prostate, scrotal surgery, and transurethral resection of bladder tumor were most common among the other types. Medications that could limit postoperative pain were not routinely given intraoperatively.

Putting the project in context, Dr. Mishra cited research showing that one of every 48 patients who are prescribed a new opioid in the emergency room becomes a long-term opioid user. In addition, he said there are ample data showing that the majority of patients who become addicted to opioids initially gained access to the medications through a prescription written for them or a family member.

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“Opioid addiction is an issue that permeates all levels of society regardless of age, gender, race, or income level, and it is a particularly salient topic in the state of Ohio that ranks third in the nation for its rate of opioid-related deaths,” Dr. Mishra told Urology Times.

“It is important that physicians become proactive in efforts to curtail the usage of opioids in the community.”

The study Dr. Mishra presented has a planned enrollment of 150 patients and patient recruitment is ongoing. In parallel with the research, another randomized prospective study is underway evaluating whether administering music therapy immediately postoperatively affects pain after robotic urologic surgery.

“Preliminarily, it appears the intervention is associated with significant reduction in pain medication use. As we explore various strategies to address the problems of opioid usage, we are encouraged that this minimal-risk intervention may have clinically significant benefit,” Dr. Mishra said.