The United States has seen a dramatic increase in opioid prescribing, resulting in unforeseen consequences. These practices are a result of policy changes dating back several decades wherein pain was reinforced as the fifth vital sign. "These policy changes prompted significant variations in our approach for postoperative pain control, and today, we face what many consider to be an opioid epidemic," says Matthew (Matt) J. Ziegelmann, M.D., a urologist at Mayo Clinic's campus in Rochester, Minnesota. "Some studies estimate that surgeons are responsible for approximately 10 percent of all opioid prescribing, and a recent report found that more than 5 percent of patients who received a prescription opioid for postoperative pain control continued to use that medication for a prolonged period, suggesting the possibility of dependence."
Authorities are taking action, and policy changes have been proposed and implemented to limit overprescribing. However, to date, there is relatively little evidence basis upon which to guide postoperative opioid prescribing, particularly for urologists. "Mayo Clinic has sought to be at the forefront in the fight to stem opioid overprescribing," says Dr. Ziegelmann. "We therefore convened a multidisciplinary Urology Opioids Task Force in mid-2017."
The task force included urologists, anesthesiologists, pharmacists, nurses and health services research experts from Mayo Clinic campuses in Minnesota, Arizona and Florida. Its first goal was to assess institutional postoperative prescribing practices. For study results published in The Journal of Urology in 2018, the task force identified over 11,800 patients who underwent one of 21 common surgical procedures at our institution between January 2016 and December 2017. Eighty percent of patients were prescribed an opioid medication postoperatively, with a median quantity prescribed of 150 oral morphine equivalents (equal to approximately 18 5-mg oxycodone tablets).
Prescribing patterns across surgical procedures
"There was significant variability in both the quantity of opioids prescribed and the percentage of patients who received a prescription refill as well," says Dr. Ziegelmann. "We found this data enlightening, and it provided the impetus to create a more standardized approach to postoperative opioid prescribing."
The task force then sought to develop a postoperative opioid prescribing guideline for common urologic surgical procedures. After considering several options, the task force determined that a tier-based approach was optimal, as opposed to 21 separate guidelines.
Dr. Ziegelmann notes: "The aim was to create an easy to implement, easy to modify guideline that would encourage provider consistency while also accounting for anticipated differences in postoperative pain associated with procedures of varying levels of invasiveness. We anticipated that recommending any drastic changes to prescribing practices amongst over 30 different surgeons would result in compromised guideline adherence. As such, the historical prescribing data derived from the aforementioned analysis, along with expert opinion, was used as the basis for the first iteration of our opioid guideline."
Mayo Clinic Urology postoperative opioid prescribing guidelines for opioid-naive patients
Procedures with similar levels of perceived pain (based on a critical assessment of historical data) were grouped into four tiers, and a maximum recommended quantity of opioids was agreed upon by task force members.
Dr. Ziegelmann continues: "We chose to focus on adult patients without a history of chronic opioid use or abuse undergoing urologic surgery, and emphasized nonnarcotic pain regimens as first line treatment. The guideline was disseminated throughout the institution to everyone involved in perioperative and postoperative patient care at all three Mayo Clinic campuses over a period of several months. It was officially implemented into clinical practice on Jan. 1, 2018.
"Looking ahead, the next goal for our institutional opioids task force is to assess changes to postoperative prescribing practices after guideline implementation. It is important to note that the first iteration of our guideline was based on historical prescribing data and does not take into account patient utilization of the medications that are prescribed.
"Notably, a group from Mayo Clinic performed a prospective phone survey of greater than 2,400 patients who underwent multiple different surgical procedures in a variety of surgical specialties, including about 200 patients who underwent either robotic prostatectomy or minimally invasive nephrectomy. In study results published in the Annals of Surgery in 2018, the authors report that greater than 60 percent of opioids went unused, and 30 percent of patients did not use any opioids after dismissal. This data has been corroborated by other institutions and suggests a disconnect between patients and prescribers.
"As was previously stated, we chose to hold off on making drastic prescribing changes in order to ensure buy-in from all involved parties. We anticipate that patient utilization data will be incorporated into future guideline iterations in order to further optimize opioid prescribing at our institution and beyond."
For more information
Ziegelmann M, et al. MP80-04 Wide variation in postoperative urologic surgery opioid prescribing in tertiary care centers. The Journal of Urology. 2018;199:e1090.
Thiels CA, et al. Results of a prospective, multicenter initiative aimed at developing opioid-prescribing guidelines after surgery. Annals of Surgery. 2018;268:457.