Decreasing Opioid Use After Urologic Cancer Surgery


Can providers decrease opioid prescriptions after surgery, while still managing care adequately?

About 6 percent of patients who have never received opioids before become addicted after being prescribed these drugs following surgery, according to a 2017 study published in JAMA.

So, care teams at Standard Health Care and The University of Texas MD Anderson Cancer Center sought to decrease the amount of opioids prescribed after urologic cancer surgery, without compromising pain control.

The study involved 443 patients, and by the end, post-surgery opioid use was cut nearly in half.

The researchers started off by examining their current opioid prescribing practices. Ultimately, they realized that the main reasons for prescribing included: patient satisfaction, a lack of knowledge about other drugs (referred to as adjuncts) that can be used to mitigate pain and the belief that adjuncts are not as effective in mitigating pains as opioids are.

“So, based on this, we decided to target those,” Kerri Stevenson, MN-NP, NP-C, a nurse practitioner who works in inpatient urology at Stanford Health Care said while presenting the findings at the 2018 ASCO Quality Care Symposium. “Our key drivers were really focused on appropriate prescriptions, increasing patients’ and provider awareness, standardizing our pathways and setting expectations.”

The team started out with provider education about appropriate prescriptions. Just this step had major change, as Stevenson noticed much more discussion about opioids and a drop in their usage.

Then, the researchers standardized their opioids prescription pathways. They tightened their control of prescribing, instead using agents such as Tylenol, gabapentin and Toradol. When they did prescribe opioids, they started with the lowest possible dose and increased as needed.

“There’s a lot of guidelines for chronic pain management, oncological pain management — but what about surgery? That’s the time to use an opioid,” Stevenson said. “Patients have acute pain. We must treat it, and there are very little guidelines out there.”

Direct and easy-to-understand communication between patients and providers also proved to be important in prescribing medication to manage pain, Stevenson said.

“Speak with functional language,” Stevenson said. “We’re not going to take all your pain away, but we want you moving around. We want you walking. We want you doing things you want to do and to work toward those goals. Give hope that the pain will improve every day.”

In doing so, Stevenson said that instead of asking patients if they would like an opioid, such as oxycodone, they should say something like, “You’re already on Tylenol, gabapentin and Toradol. These all work in different ways. How is it working for you?”

Ultimately, there was a 46 percent decrease in opioid use after surgery. But that led Stevenson to ask, “So the magic question is: Are we just undertreating patients?”

That turned out not to be the case. For the first 24 to 28 hours prior and post interventions, there was no change in pain scores. Moving forward, the researchers plan to expand their opioid-reduction strategy to general urology, pediatric urology and other surgical services.

“All in all, from the topic of opioids, we’ve only began to start to look at this,” Stevenson said. “There’s so much more direction and path that we can go, even in our own data.”

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