New Intervention Protocol Shows Efficacy in Reducing Opioid Prescribing After Urologic Surgery

November 26, 2020

The current COVID-19 pandemic may have supplanted discussions in the media concerning the ongoing epidemic of opioid use and abuse in the United States, but health care systems and providers should make no mistake: opioid use in this country remains at crisis levels. Health care systems and providers also should understand that prescribing patterns of opioids after medical and surgical procedures is partly to blame for the flood of opioids around the nation.

Grappling with the epidemic and its consequences requires a concerted, multidisciplinary, and multi-institution collaboration between health care providers, patients, and governmental bodies. However, to wrestle the problem into submission, it is first necessary to understand the causes and then design protocols, policies, and interventions to stem the crisis and reduce the excess and unwarranted flow of narcotic pain medications into the community.

The Department of Urology at UPMC has been a leader in researching causes and contributing factors to the opioid epidemic, and designing and testing interventions and policies around the use of opioid pain medications prior to, during, and after urologic surgery. Among others, Benjamin J. Davies, MD, and Bruce L. Jacobs, MD, MPH, have spearheaded this research and clinical protocol changes in collaboration with Department colleagues and colleagues in anesthesia, nursing, and internal medicine.

The latest research from their collective efforts was recently published in the journal Cancer, from the American Cancer Society. The new study, “Large Reduction in Opioid Prescribing by a Multipronged Behavioral Intervention After Major Urologic Surgery,”1 provides data on the design and testing of a multi-pronged behavioral intervention targeted at improving and reducing urologic surgeons prescribing of opioids in two cohorts of patients: prostatectomy and nephrectomy.

Study Overview and Primary Results

"Individual surgeons and physicians have a huge role to play in curbing opioid use. It begins with more judicious use of opioids, and it also entails utilizing more effective multimodality pain control protocols that can significantly reduce or even eliminate the need for opioids after surgery. However, ingrained and long-standing behaviors and clinical practice standards are difficult to change. The approach we tested in this study was designed to help surgeons – specifically urologic surgeons in our system – recognize and understand their behavioral patterns with opioid prescribing and work to change it. It sounds simple, but we would have already quashed this crisis if that were really the case. So, the work must continue," says Dr. Davies.

The new study is the first to show profound decreases in the prescription of opioids by surgeons to patients who have undergone a “major surgery” after having participated in a focused behavioral intervention or training program.

Briefly, the designed intervention consisted of three parts, and the study was ordered in three phases. The intervention included formal education on opioid prescribing, direct and individual feedback to each surgeon on their prescribing habits, and direct comparison of individual surgeon patterns against their peers (department colleagues). The study was conducted with a pre-intervention phase, an intervention phase, and a postintervention or "washout" phase.

Thirteen urologists from the Department participated in the study, and their combined surgical volumes during the study included 382 cases of prostatectomy and 306 cases of nephrectomy. In order to understand prescribing patterns, baseline-numbers were derived for each surgeon prior to the intervention, and this number was compared against their numbers during and after the intervention. The study used a measure of oral morphine equivalents (OMEs) to gauge opioid quantities prescribed.

"In terms of numbers, the results were dramatic," says Dr. Jacobs. The median number of OMEs in the prostatectomy patient cohort dropped from 195 to 19 after the intervention. It was even greater for the nephrectomy cases, decreasing from a mean of 200 OMEs to zero. Not only that, those patterns persisted and were durable after the intervention ceased."

Patient-reported Outcomes Assessments

The secondary end point of the study examined and compared various patient-reported outcomes measures between the opioid and no opioid groups in each surgical cohort. Patients in each cohort had similar experiences after surgery. The only discernible difference was that prostatectomy patients discharged with opioid pain medication reported higher levels of anxiety versus those receiving no opioids at discharge, and they also reported more anxiety than nephrectomy patients. There were no measurable differences between patients discharged with and without opioids for the other outcomes, including: perception of pain, activity levels, sleep disturbances, behavioral health symptoms, and other postoperative complications, such as nausea and dizziness.

Key Takeaway

"Here is the takeaway: With diligence on the part of surgeons and a willingness to embrace new modes and methods of care, and with focused education and intervention coupled with globally refined surgical and postoperative pain control methods, we can dramatically curb the over-prescription and consequent use and potential addiction to opioids by our patients. Anything short of that should be seen as a failure with grave consequences for all of us. We can put help to put an end to opioid misuse and overprescribing if we can muster the collective will do so," says Dr. Davies.

Reference

1. Jacobs BL, Rogers D, Yabes JG, Bandari J, Ayyash OM, Maganty A, Armann KM, Worku HA, Pace NM, Shah A, Pekala KR, Yu M, Chelly JE, Macleod LC, Davies JB. Large Reduction in Opioid Prescribing by a Multipronged Behavior Intervention After Major Urologic Surgery. Cancer. 2020; 0: 1-9. Epub ahead of print.

Further Reading

Below is a selection of recent research studies and editorials from UPMC Department of Urology faculty related to their ongoing studies of opioid use.

Myrga JM, Macleod LC, Bandari J, Jacobs BL, Davies BJ. Decrease in Urologic Discharge Opioid Prescribing After Mandatory Query of Statewide Prescription Drug Monitoring Program. Urology. 2020 May; 139: 84-89.

Yu M, Davies BJ. Opium Wars to the Opioid Epidemic: The Same Narcotics Cause Addiction and Kill. Eur Urol. 2020 Jan; 77(1): 76-77.

Pekala KR, Jacobs BL, Davies BJ. The Shrinking Grey Zone of Postoperative Narcotics in the Midst of the Opioid Crisis: The No-opioid Urologist. Eur Urol Focus. 2020 Nov 15; 6(6): 1168-1169.

Theisen KM, Davies BJ. A Radical Proposition: Opioid-sparing Prostatectomy. Eur Urol Focus. 2020 Mar 15; 6(2): 215-217.

Theisen K, Davies BJ. The American Opioid Crisis: The Inexorable March to Death and Addiction. Eur Urol. 2019 Feb; 75(2): 219-220.

Lee AJ, Bandari J, Macleod LC, Davies BJ, Jacobs BL. Concentration of Opioid-Related Industry Payments in Opioid Crisis Areas. J Gen Intern Med. 2019 Feb; 34(2): 187-189.

Theisen KM, Myrga JM, Hale N, Cochran G, Sewall C, Macleod LC, Jacobs BL, Davies BJ. Excessive Opioid Prescribing After Major Urologic Procedures. Urology. 2019 Jan; 123: 101-107.

Macleod LC, Turner RM 2nd, Lopa S, Hugar LA, Davies BJ, Ben-David B, Chelly JE, Jacobs BL, Nelson JB. Effect of Multimodal Analgesia With Paravertebral Blocks on Biochemical Recurrence in Men Undergoing Open Radical Prostatectomy. Urol Oncol. 2018 Aug; 36(8): 364.e9-364.e14.