Patients can be successfully managed with minimal opioid medication after urologic oncology surgery, said Kerri Stevenson, MN, NP-C, RNFA, CWOCN, Lead Advanced Practice Provider – Interventional Radiology, Stanford Health Care, CA, at the 2018 ASCO Quality Care Symposium. She presented results from a 4-month study conducted at Stanford Health Care. Over the course of the study, patients were able to decrease their opioid use after surgery by 46%, without compromising pain control.
Patients are often prescribed opioids for acute pain after oncologic surgery. For many, this is their first encounter with opioids, and approximately 6% of opioid-naïve patients are newly addicted to these substances at 90 days postsurgery.
“There are a lot of guidelines for chronic oncologic pain management, but what about surgery?” asked Ms Stevenson. “That’s the time to use an opioid; that’s when patients have acute pain. We have to treat it, but there are very few guidelines out there for how to do it,” she said.
Targeted Intervention Cuts Opioid Use in Half
As a high-volume surgical department, Ms Stevenson and her team set up a study with the goal of reducing postoperative reliance on opioids for pain control by 50%—from a baseline morphine equivalent daily dose (MEDD) of 95.1 to 47.5 MEDD.
The team retrospectively reviewed daily opioid use, pain scores, and anxiety scores in 443 patients who were recovering from surgery for urologic cancer at their institution. Through the use of a provider survey, they pinpointed the key drivers for excess opioid use.
These key drivers included patient satisfaction—treating pain as the fifth vital sign—and the lack of patient and provider knowledge of the availability and efficacy of nonopioid medications.
The team designed alternative pain regimens with varying combinations of acetaminophen, ketorolac, gabapentin, and local anesthetic, and then developed interventions to facilitate the adoption of these novel, opioid-sparing pain treatment regimens.
“Our key drivers were really focused on appropriate prescriptions, increasing patient and provider awareness, standardizing our pathways, and setting expectations,” Ms Stevenson said.
They educated their providers on the new opioid-sparing pathways for patients with routine pain (as opposed to those with chronic pain), and revised their Epic order sets to default to opioid alternatives.
“Once we started our interventions, we noticed an immediate effect,” she said. “We saw a significant and dramatic drop [in opioid use].”
The team evaluated outliers, which indicated higher opioid use, and found that in the majority of the cases these could be attributed to patients with a history of opioid use.
The implementation of these interventions led to a reduction in opioid requirements across multiple surgery types, ranging from robotic prostatectomy (55.1 MEDD) to open radical cystectomy (50.6 MEDD).
To ensure they weren’t simply undertreating patients’ pain, the investigators evaluated pain scores and found no increase in 24- or 48-hour postoperative pain scores associated with the use of these opioid-minimizing pathways. Similarly, they saw no change in anxiety scores at 24 and 48 hours after surgery.
Oncologists Can Make a Difference
“How we speak to our patients has a huge impact on their perception of their care,” said Ms Stevenson. She noted the importance of clear communication with patients regarding the pain management protocols that are already in place.
“Avoid language like, ‘You haven’t had any pain medicine’ (not mentioning to the patient that he or she is already on acetaminophen, gabapentin, and ketorolac). ‘Would you like me to bring you some oxycodone?’ Instead, shift that language to, ‘Let’s discuss your pain control. How are you feeling today? You’re already on acetaminophen, gabapentin, and ketorolac. These all work in different ways. How is it working for you? Do you think you need something a little stronger?’”
Speak with functional language, Ms Stevenson says, such as, “We’re not going to take all your pain away, but we want you up and moving around.” Work toward set goals, and give patients hope that their pain will improve each day, she advised.
“Ultimately our goal is good pain control, but a lot of patients don’t feel well on opioids. They become a benign medication that we prescribe, but they make a lot of people feel cloudy, foggy, or confused,” Ms Stevenson said.
With extremely small doses, many patients achieve effective pain control with fewer side effects (such as constipation).
Ms Stevenson stressed the following points:
- If opioids are necessary, start with the lowest dose and increase as needed
- Target the right pain medication for the correct type of pain
- Discuss side effects with patients
Based on their success within the urologic oncology department, Ms Stevenson and her team plan to apply these interventions to benign urology and pediatric urology, as well as to other surgical services within their institution and beyond.
“In the nationwide effort to combat the opioid epidemic, healthcare providers can play a pivotal role as gatekeepers by decreasing reliance on opioids in the postoperative period,” she said.