The opioid epidemic was first declared by the CDC in 2011 when the percentage of all deaths due to unintentional opioid toxicity was 1.8%. Despite widespread recognition and efforts in the following years, the death rate has continued to increase, and 4.5% of all deaths in the United States were attributable to opioid toxicity in 2021.¹ Surgeons are a minor but unique source of opioid prescribing due to the iatrogenic nature of surgical pain. The relationship between surgery and opioid prescribing or the opioid crisis was rarely described in the literature before 2016 (Figure). Although the exact etiology is variable, up to 10% of opioid-naïve patients have persistent opioid use > 3 months after major surgery which can serve as a risk factor for opioid use disorder.² Rates of persistent opioid use are lower after minor urologic procedures at about 2% in 1 Canadian study, but patients receiving a prescription were still at higher risk of long-term use (odds ratio 1.4) and opioid overdose (odds ratio 3.0).³ Urologists have a responsibility to promote awareness and action for our patients as part of the opioid crisis.

Personally, my initial experience with the opioid crisis stemmed from an ambulance ride along that responded to heroin abuse and overdose calls in Baltimore. I didn’t think much about opioid prescribing as a junior resident when I started in 2014. We had established postoperative protocols for inpatient recovery and breakthrough pain where the task of placing orders became mechanical, and discharge prescriptions were often written well before we knew how a patient would feel at the time of discharge. Electronic prescribing of opioids was not yet employed, and reducing phone calls for your colleague on call was a priority. However, as I planned quality-improvement initiatives and studies in 2016 before my research year, discussions around opioid prescribing after surgery began to surface, and we quickly realized how little we knew about how much patients needed or used after leaving the hospital. I did an internal survey of faculty and residents to see what they thought constituted “appropriate” prescribing and then used radical prostatectomy as a case example for a prospective quality-improvement study to measure what we prescribed and how much patients used in 2017. Using baseline data showing 77% of opioid tablets went unused, I got buy-in and planned an evidence-based intervention employed in 2018 to change our default prescribing habits and provide patients with an educational sheet at discharge. All in all, I called and learned about the pain experience of 443 patients. We found that a very low-touch intervention reduced prescribing by almost 50%, actual opioid use by 27%, and doubled the rate of disposal for leftover medications.⁴ In terms of provider burden, only 1% of patients sought an additional prescription for pain.

While I provide this example as a tangible effort derived from awareness and action, data from other institutions quickly pushed efforts further demonstrating opioid-free discharge was a feasible goal for many patients undergoing radical prostatectomy or nephrectomy procedures.^5,6 Advocacy efforts built on the emerging data through revision of recommendations on appropriate prescribing and manifested through the AUA with a white paper in 2021 outlining strategies for urologists to consider to reduce opioid prescribing and its downstream effects.^7,8 A question that arises from our progress to date is whether the ultimate goal for urologists is to stop prescribing any opioid medications? In my opinion, the goal is rational prescribing based on the procedure and patient. While opioids add little value to effective nonopioid strategies (eg, NSAIDs, acetaminophen, tamsulosin, oxybutynin, phenazopyridine, local analgesia) for minor urologic procedures, they still serve a role for patients with acute pain after major urologic operations. Patients requiring no opioids in the 12 hours prior to discharge can clearly avoid a prescription, but pain scores and inpatient use directly translate to postdischarge use where a 2-day supply may be reasonable to bridge recovery and facilitate appropriate discharge.⁹

Overall, urologists now have the awareness and resources to reduce opioid prescribing in an active rather than passive fashion, which can be done at several points of care. First, setting patient expectations begins with the visit where you recommend a procedure to a patient whether it be a vasectomy, prostate biopsy, ureteroscopy, or major operation. In most cases, we can emphasize that minimal or no opioid medications will be required, set a goal for manageable rather than zero pain, inform patients if local analgesia will be applied, and reassure them that severe pain will be taken seriously. Patients on chronic opioid medications prior to surgery benefit if we communicate with their primary care provider or pain specialist, and patients undergoing open surgery can consider receiving an epidural or block. Second, reinforcement on the day of the procedure and presenting a collaborative plan with anesthesia colleagues are helpful. Third, assessing postoperative pain and inpatient opioid use at discharge can set postdischarge expectations. Discharge instructions can include default language on nonopioid strategies, management of opioid side effects on bowel function, and appropriate disposal for patients receiving a prescription. Electronic prescribing has also improved both access and monitoring of opioid medications for patients requiring them after discharge.

Through setting patient expectations, making changes in our clinical flow, and incorporating emerging data, urologists play a relevant role in the opioid crisis and have an impact on the quality of life of our patients. We can advocate for state and national efforts to curb the opioid epidemic and utilize tools that did not exist just a few years ago including electronic prescribing and prescription drug-monitoring programs. In our practices, sequential stepwise or tapered changes can be undertaken to reduce prescribing or incorporate evidence-based interventions to measure impact.⁸ Additionally, it is upon us to study new strategies for opioid reduction before recommending widespread use to confirm whether there is a measurable benefit in the target population.¹⁰ With the opioid crisis nowhere near the end, we can continue to strive to do better.