Opioid abuse is a growing public health problem, with drug overdose deaths surpassing 93,000 in 2020, a 29% increase from 2019.¹ Reliance on opioids after surgical procedures plays a large part in this epidemic. Of those who use heroin, about 80% first misused prescription opioids.² Up to 80% of prescribed opioids are left unused after commonly performed surgeries.^3,4 Unused medication poses a risk to individuals and communities for nonmedical usage, diversion and unintentional overdose.⁵ Existing prescribing guidelines only cover limited types of procedures,^6,7 are not well known or utilized⁸ and are reliant on phone call surveys that are difficult to scale.^4,9 As a result, prescribing practice varies greatly for each procedure¹⁰ with studies showing large prescription amounts for low acuity procedures such as cystoscopy, transurethral resections of the prostate and vasectomies. Decreasing the amount of unused opioids while balancing adequate pain management remains a priority for surgeons and for the broader public health.

There are certain essential components that should be considered to improve opioid stewardship and decrease the overall impact of opioid overprescription on opioid abuse:

1. Decrease (eliminate) opioid use
2. Use existing guidelines
3. Use nonopioid options
4. Dispose of unused opioids

Opioids Are Overprescribed… and We Can Prescribe Less

Opioids are overprescribed by a large amount across a wide variety of procedures. Up to 80% of opioids prescribed after commonly performed urological and surgical procedures are left unused.^3,4 Multiple studies have substantiated that for certain common procedures, such as robotic prostatectomies, opioid prescriptions can be virtually eliminated.¹¹

One of the biggest barriers to decreased opioid use among providers has been a concern regarding preventable phone calls.⁸ Surgeons may prescribe more than twice the needed amount of opioids to avoid unnecessary phone calls.¹² However, multiple groups have demonstrated that interventions reducing opioid prescriptions, according to evidence-based recommendations, can significantly decrease the number of unused opioid tablets while maintaining similar quality of life scores and without increasing unplanned emergency room visits or phone calls.^6,7,13

Prescribing Less Is Good… But How Much Should We Prescribe?

Prescribing the right amount of opioids is dependent on knowing the amount of opioid needed for each procedure, understanding patient-reported pain and recovery outcomes and being able to predict who may or may not need opioids. Multiple groups have measured patient-reported usage of opioids after certain common urological procedures and have published suggested guidelines for select procedures.^4,7,13 However, awareness of existing guidelines among providers is quite low, and utilization of guidelines can be difficult if they are not readily available at the time the opioids are being prescribed.⁸ Furthermore, existing guidelines for urological and surgical procedures only cover a portion of procedures,⁴ are largely based on expert opinion,⁷ are reliant on patient recall and phone surveys,¹⁴ and do not have patient-reported, prospective data (table 1). Using newer technology interfaces, such as text messaging services that can link with the electronic health record, provides a scalable opportunity to engage postoperative patients and collect patient-reported outcomes and opioid use directly from the patient at the point of care.¹⁵ As part of the opioid task force at the University of Pennsylvania, we published preliminary data utilizing a text messaging program of 177 patients undergoing a variety of urological procedures, which found that 60% of tablets were left unused and 75% of patients took fewer than 5 opioid tablets following surgery,¹⁵ far lower than the national mean prescribed after these procedures.¹⁶ An updated analysis of over 1,500 patients undergoing more than 100 unique urological procedures is under review for publication. Using the patient-reported data, we created potential evidence-based guidelines for individual procedures based on the amount of opioid pills used by the 75th percentile for those procedures, which may provide some clarity on how to prescribe the appropriate amount of opioids for a variety of endoscopic and major open surgical procedures (table 2). Further collaborative studies need to be done in this space to help measure, test and validate how we can provide the best level of care for our patients.

Nonopioid Options Work

Many studies have shown the benefits of multimodal pain management, providing effective pain relief without the potential side effects of opioids and decreasing the risk of overall opioid overprescription. Although multiple treatment options have been described, they all include some combination of the following:

• Acetaminophen: has been shown to be effective to reduce pain in postoperative settings;* can be used in combination with NSAIDs and have a synergistic effect on pain relief.*
• NSAIDs (such as ketorolac): have been shown to have efficacy in the postsurgical setting, especially for the treatment of acute renal colic and after endoscopic urological procedures.
• Local anesthetics: especially those given as transversus abdominis plane (TAP) blocks, have been used to provide local pain control and reduce overall opioid requirement. TAP blocks have been essential for use in the Enhanced Recovery After Surgery (ERAS) pathways to provide an opioid-free recovery. Utilizing bupivacaine or long-acting formulations with liposomal bupivacaine (eg Exparel®) has been shown to significantly decrease opioid requirement, although the data are mixed on the true efficacy of liposomal bupivacaine, which is significantly more costly.

Dispose of Unused Opioids

Facilitating opioid disposal may be an important lever to decrease the overall availability of opioids. Although opioid disposal or safe storage rates vary from study to study, the actual disposal rate for most of the larger observational studies rarely exceeded 9%.³ Patients may keep opioids for future use or a “rainy day” and to help other friends or relatives manage their pain.¹⁷ This may be a preventable avenue for abuse, as almost 70% of patients surveyed by the Substance Abuse and Mental Health Services Administration (SAMHSA) got their most recent opioid tablet from a friend or relative.¹⁸

There are multiple ways to dispose of opioids properly, including returning them to designated disposal locations, utilizing shippable deactivation devices such as charcoal bags or flushing them down the toilet.¹⁹ Asking patients to remember to find disposal centers and remember to bring unused opioids is inconvenient for most patients and therefore presents a significant barrier to compliance for most patients. Charcoal bags can be an effective means to improve disposal, as providing charcoal bags to patients after surgery can double the rate of disposal;²⁰ however, scalability to larger health systems may be difficult to manage. Providing information about flushing opioids may be helpful, as the most commonly prescribed opioids, including oxycodone, hydrocodone and hydromorphone, are all included on the list of medications that are allowed to be flushed.¹⁹

Conclusion

Opioids are greatly overprescribed for urological procedures. We can decrease opioid prescriptions while still providing good patient care. We can follow and disseminate information on opioid prescribing guidelines. Nonopioid alternatives may be helpful to reduce the need for opioids postoperatively. Facilitating opioid disposal can help decrease availability of opioids for abuse. More implementation studies are needed in this space to test and evaluate the best methods for improving the quality of care in opioid stewardship.