Comparison of prescribing patterns before and after implementation of evidence-based opioid prescribing guidelines for the postoperative urologic surgery patient
Introduction
Policy updates wherein pain was reinforced as the “5th vital sign” prompted substantial changes in our approach to pain control, and we have seen a dramatic increase in opioid prescribing, resulting in unforeseen consequences.1 The drug-overdose death rate tripled over the past two decades, and 40% of these deaths involved a prescription opioid.2,3 As a result, we currently face an opioid epidemic. Surgeons play an important role, as we prescribe an estimated 10% of opioids, and more than 5% of opioid-naïve patients who are prescribed opioids may realize new persistent use after the index procedure.4,5 In fact, a recent study from Howard and colleagues suggested that the quantity of opioids prescribed by surgeons was independently associated with the amount of opioids consumed by patients postoperatively.6
Authorities are taking notice, and targeted approaches are underway to curb excessive opioid prescribing.7 Enhanced recovery protocols, which call for the use of non-opioid medications including local anesthetics, non-steroidal anti-inflammatories (NSAIDS), acetaminophen, anti-spasmodics, and anti-convulsants, are one such approach to limiting opioid prescribing that have shown promise.8,9 Guidelines for postoperative opioid prescribing are another approach that has shown some progress with supportive early results.10, 11, 12 However, the majority of such guidelines pertain to one or only a few surgical procedures, and the availability of readily-accessible evidence-based guidance for postoperative pain management specific to urology is severely lacking.9,11,13
In our own practice, we previously identified significant variation in opioid prescribing practices amongst a large group of urologic surgeons, and saw this as an impetus to introduce standardized prescribing practices.14 We hypothesized that a more standardized approach to opioid prescribing would significantly change prescribing patterns at our institutions. Herein, we describe the development and implementation of an evidence-based opioid prescribing guideline for common urologic procedures, and compare prescribing patterns in the time period before and after the guideline dissemination.
Section snippets
Materials and methods
We convened a multi-disciplinary opioid task force with representatives from urology, anesthesiology, nursing, pharmacy, and health-services research in June 2017 to evaluate departmental opioid prescribing. Administrative billing data was used to identify patients ≥18 years of age who underwent one of 21 common urologic procedures at our three affiliated medical centers in Minnesota, Arizona, and Florida between January 1, 2015 and December 21, 2016. Patients who underwent more than one
Results
Prescribing data [Supplementary Table 2] for opioid naïve patients undergoing 21 urologic procedures for the years 2015–2016 (n = 9253) was used to develop our four-tiered guideline.21[Table 1] Opioid prescribing was compared amongst patients who underwent surgery between January 1, 2017 and April 30, 2017 (before guideline implementation, n = 1732) and those who underwent surgery between January 1, 2018 and April 30, 2018 (after guideline implementation, n = 1376).
The median OME (IQR)
Discussion
Here, we demonstrated that providing a large, diverse group of urologists with a simple, easy to follow guideline resulted in real changes in opioid prescribing. In essence, our data support that physician “buy-in” with standardized prescribing is possible, even amongst a heterogeneous group of urologic surgeons at multiple institutions with varying practice patterns. We hypothesized that a loftier goal such as recommending drastic cuts to opioid prescribing, while desirable in the long term,
Conclusions
We report our urologic-surgery specific, evidence-based guideline for postoperative opioid prescribing in the adult opioid-naïve patient. Upon implementation of the guideline, we found that fewer opioids were prescribed and there was greater consistency amongst providers. Further work, including the incorporation of patient utilization data, is necessary to ensure congruity between provider and patient expectations for postoperative pain management.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors have no relevant conflicts of interest to disclose.
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