From the 2018 HVPAA National Conference
Kathryn Hacker (University of North Carolina at Chapel Hill), Hannah Cook (UNC Eshelman School of Pharmacy), Jae Jung (UNC Eshelman School of Pharmacy), J. Lee Graves (UNC School of Medicine), Peggy McNaull (UNC School of Medicine), Brooke Chidgey (UNC School of Medicine), Jami Mann (UNC Hospitals), Angela Smith (UNC School of Medicine), Matthew Nielsen (UNC School of Medicine)
The incidence of new persistent opioid use following surgery is 6-10%, more common than any single post-operative complication. Additionally, recent systematic review found 67-92% of patients report unused opioid medications after a surgical prescription. Reducing opioid oversupply may substantially impact the opioid epidemic as a primary and secondary prevention strategy.
To evaluate opioid requirements of patients following radical cystectomy and risk factors for higher opioid use. We will utilize this data to improve post-operative prescribing practices through standardized clinical pathways and prescribing schedules.
Patients who previous underwent radical cystectomy at the University of North Carolina were identified and a retrospective analysis of inpatient opioid requirements post-operatively was performed. We evaluated the association of the amount of opioid use with demographic characteristics, pre-operative diagnoses, cancer characteristics, post-operative complications, and cancer recurrence. Additionally, we evaluated post-discharge opioid use and obtained details regarding medications prescribed for postoperative pain through our pharmacy database. Two weeks post-procedure, patients were contacted to participate in a survey evaluating postoperative opioid usage and disposal habits.
Following radical cystectomy, inpatients utilize a wide range of morphine equivalent amounts. After discharge, 11 of the 28 patients who underwent a radical cystectomy during the 6 month study period were surveyed. These patients were prescribed an average of 34 tablets of 5 mg oxycodone and 80% filled this prescription. Patients reported an average of 22 tablets unused and 55% reported having received counseling on proper disposal of narcotic medications. Interestingly, only 1 of 7 patients with unused medication disposed of the oversupply of opioid pills. The remainder of the patients did not dispose of the medication since they didn’t consider disposal (3/6), saved it in case they needed additional pain medications (2/6), and didn’t know how to dispose of it properly (1/6).
Inpatient opioid use following radical cystectomy displays a wide range of opioid requirements which vary based on patient and surgical characteristics. However, following discharge, we identified that patients are receiving an oversupply of opioid medications and are not appropriately disposing of this medication.
Implications for the Patient
Multimodal pain control for inpatients and development of data-driven post-operative prescribing schedules will potentially allow urologists to decrease opioid prescriptions following radical cystectomy. Additionally, pre-operative and post-operative counseling on proper storage and disposal may help reduce diversion potential and decrease the misuse of opioid prescriptions following urologic surgeries.