Opioids prescribed by medical practitioners contribute significantly to opioid-related deaths due to prescription diversion and opioid abuse.¹ Despite years of regulations, the opioid abuse crisis continues to remain a major public health concern, claiming more than 68,000 lives due to opioid overdose in 2018.² Thus, the impetus to use all available measures to reduce dissemination of prescription opioids remains essential. With emphasis on nonopioid analgesics, enhanced recovery after surgery (ERAS) protocols have demonstrated successful reduction in the use of opioids during hospital stay to facilitate early discharge. We studied the impact of initiating ERAS protocols on the opioid prescriptions given at discharge after major urological cancer surgery.

Materials and Methods

We reviewed the medical records of 409 patients undergoing robotic radical prostatectomy, open or robotic nephrectomy (radical or partial), or radical cystectomy from 2016 to 2018. Discharge instructions included use of acetaminophen and/or ibuprofen prior to using opioids for breakthrough pain. The type and amount of opioid prescriptions given were based on the discharging provider’s assessment of pain control and necessity of opioid prescriptions at discharge. We also reviewed the outpatient records of patients on ERAS protocols for 30 days after discharge to identify any additional opioid prescriptions. Primary outcomes included the difference in the number (mean±SD) of standardized hydrocodone 5 mg tablet equivalents prescribed at discharge before and after initiating the ERAS protocols, as well as the type of opioids prescribed.

Results

Of the 409 patients, 207 (51%) underwent surgery before ERAS and 202 (49%) after ERAS protocol implementation. Robot-assisted laparoscopic approach was used in 285 cases, with 158/285 (55%) before ERAS. Patient characteristics are outlined in table 1. There was a significant difference in the type of opioid medications prescribed after ERAS implementation, as tramadol was prescribed at a significantly higher rate than hydrocodone or oxycodone (p <0.001).

Figure 1. Reduction in standardized opioid tablets prescribed in patients treated under ERAS protocol for various procedures.

There was a significant decline in the mean opioid tablets prescribed at discharge after initiating ERAS (fig. 1). After ERAS, opioid tablets decreased by 38.2% (mean±SD 49.7±15.4 vs 30.7±18.5 tablets, p <0.001) following open radical and open partial renal procedures, and by 34.6% (37.6±14.6 vs 24.6±14.3, p <0.001) following robotic renal procedures. In robotic prostatectomy and open cystectomy patients, there was a reduction in opioid tablets of 30% (mean±SD 33.2±9.1 vs 24.3±8.3 tablets, p <0.001) and 27.2% (39.0±17.1 vs 28.4±12.9, p=0.04), respectively. On multivariable analysis, ERAS protocols were independently associated with the largest decrease in post-discharge opioid prescriptions (table 2).

Figure 2. Change in type of opioid medications prescribed at discharge from hospital after implementation of ERAS protocol.

The opioids prescribed at discharge included hydrocodone with acetaminophen, oxycodone and tramadol. Before ERAS protocol, 91% of patients received either hydrocodone (24.7%) or oxycodone (67.6%). After ERAS protocol, the use of tramadol increased from 9% to 51% (p <0.001), signifying a substantial trend away from potent opioids (fig. 2).

A review of outpatient medical records of the 202 patients on ERAS protocols identified phone calls from 38 (18.8%), primarily related to Foley catheter, gastrointestinal issues, bladder spasms, pain and hematuria. Of these patients 13 (6.6%) required additional opioids. All 13 of these patients had undergone renal surgery (open in 8, robotic in 5), and 10 were under age 55 years.

Discussion

Opioid abuse and opioid related deaths continue largely unchecked, in part aided by prescription opioids. Two recent studies have brought overprescribing into stark relief. Theisen et al reported that for 155 patients, an average of 39 hydrocodone-equivalent tablets were prescribed at discharge, of which 60% remained unused.³ Raskolnikov et al reported that discharge prescription after renal surgery averaged an alarming 73 hydrocodone-equivalent tablets.⁴ Contemporary opioid prescribing habits remain quite concerning, prompting the American Urological Association to organize an opioid stewardship summit in 2018.⁵ Therefore, it is essential to identify all measures, direct or indirect, that have the potential to reduce opioid prescriptions at discharge.

In our 409 patients undergoing open or robotic surgery, there was a significant (27% to 38%) decrease in opioid prescriptions after ERAS implementation. On multivariate analysis, ERAS protocols were independently associated with decreased outpatient opioid prescriptions. The largest decrease in prescribed opioids after discharge (38%) was noted in the open renal surgery group. The smaller decrease in opioid prescription in the radical cystectomy group after ERAS (27%) was not statistically significant, likely due to the small sample size.

Concerns related to limited prescriptions of opioids include poor pain control, excessive phone calls and additional requests for refills. While pain scores were not available in our cohort, refill requests for opioids may be used as a surrogate for ongoing pain after discharge. In the ERAS group, only 6% of patients needed additional opioids. These were primarily patients younger than 55 years old who had undergone renal surgery. These data identify a subgroup of patients who could benefit from adjustments in the postoperative analgesic regimen (eg addition of cyclobenzaprine or pregabalin).

To our knowledge, this is one of only a few studies evaluating opioid prescriptions following ERAS for urological surgery. We reviewed several ERAS protocols for abdominal/pelvic surgery from other centers (including various surgical specialties) and noted that while ERAS protocols focus on reducing opioid use during hospital stay, these often do not specifically address opioid prescriptions at discharge. The mechanism of the impact of ERAS protocols on postoperative opioid prescriptions is likely multifactorial. However, it is at least partly related to an increased awareness and standardization of opioid-sparing pain management strategies, which have been brought into focus with the use of ERAS protocols. This has likely translated into fewer discharge opioid prescriptions and a trend away from more potent opioids.

Conclusions

A significant decrease in opioid prescriptions at discharge was noted following implementation of ERAS protocols for open and minimally invasive urological cancer surgery. Bringing a focus on controlling opioid use during inpatient stay was associated with a reduction in outpatient opioid prescriptions and a significant shift away from potent opioids.