“No Opioids” for Major Urologic Cancer Surgery?

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A “no-opioid” strategy greatly reduces the percentage of patients receiving opioid prescriptions after surgery for renal, bladder, or prostate cancer, reports a study in JAMA Surgery.

The cohort study included 647 opioid-naive patients undergoing open or minimally invasive radical cystectomy, radical or partial nephrectomy, or radical prostatectomy at the authors’ referral center between 2017 and 2021. In a pre-intervention period (2017–2018), 202 patients were treated, 100 during an initial feasibility study or lead-in period (2019), and 384 during the intervention period (2020–2021). The no-opioid intervention consisted of a pre-admission educational handout and post-discharge instructions for using non-opioid analgesics, without a routine opioid prescription. Acetaminophen and ibuprofen were the main non-opioid analgesics used.

The rate of opioid prescriptions at discharge decreased from 80.9% in the pre-intervention period to 57.9% during the lead-in period and to 2.2% in the intervention period. Median tablets prescribed were 14, 4, and 0, respectively. For procedures performed during the intervention period, mean and median opioid dose was 0 tablets for prostate and bladder surgery. The mean number of tablets prescribed was 0.6 for open surgery and 0.3 for robotic kidney surgery.

The intervention did not increase calls or unplanned clinic or emergency department visits due to pain. Patient surveys from the no-opioid period showed low pain scores (mean 2.5) and high satisfaction scores. Of 10 patients in the intervention group who received additional opioid prescriptions, 8 had undergone kidney surgery.

The no-opioid intervention—focused on pre-operative instruction and non-opioid alternatives—greatly reduced the use of opioid medications after major abdominopelvic surgery. The experience suggests that routine discharge opioid prescriptions can be eliminated with good pain control, low complication rates, and high patient satisfaction [Mian BM, et al. Implementation and assessment of no opioid prescription strategy at discharge after major urologic cancer surgery. JAMA Surg, published online ahead of print February 8, 2023. doi: 10.1001/jamasurg.2022.7652; https://jamanetwork.com/journals/jamasurgery/fullarticle/2801213].