High Marks for Opiate-Free Pain Control after Urologic Surgery

Opiate-free pain management did not adversely affect outcomes, including patient-reported outcomes (PROs), after three types of urologic surgery, according to two separate studies.

Patients undergoing radical prostatectomy or nephrectomy reported no worsening of pain, effects on activity or sleep, or somatic symptoms when they received opiate-free pain medication. Data from a study of patients undergoing ureteroscopy for kidney stones showed significantly lower pain intensity scores with an opiate-free protocol, and patients reported no increased pain-related interference with regular activities.

Both studies were reported during the American Urological Association (AUA) virtual meeting.

“This is really exceptional work in the sense that we’ve never really had data from any of the other many studies throughout the country, looking at patient-centric outcomes,” said Benjamin Davies, MD, of the University of Pittsburgh Medical Center, who moderated an AUA press briefing that included the two presentations. “At least in the cancer surgery realm, there’s very, very sparse data on what patients feel and what patients report.”

“I’m, personally, always shocked by opioid-free pathways, that they are even a thing, because I ‘grew up’ giving so many opioids, and now we give…nothing for anything. It’s very impressive,” he added.

Multiple studies have shown that patients who receive a first-ever opioid during surgery have about a 6% risk of becoming persistent opioid users postoperatively, said Bruce Jacobs, MD, also of the University of Pittsburgh. In an effort to reduce that risk, investigators developed a behavioral intervention targeting surgeons and their patterns of opioid prescribing. The intervention comprised three components:

• A grand rounds presentation that included a review of the opioid crisis and alternate pain management strategies
• An audit of surgeons’ prescribing practices with opportunities for comment and feedback
• Feedback to individual surgeons regarding their prescribing practices as compared with their colleagues

With regard to prescribing practices, investigators focused on the amount of opioids prescribed at hospital discharge and patient perceptions about postoperative pain management.

“We felt [patient perception] was important because it’s one thing if we drastically reduced opioid prescribing and patients were doing well, but it would be another thing if we reduced opioids and patients were complaining of significantly more pain,” said Jacobs.

Patients involved in the intervention completed the International Pain Outcomes Questionnaire, which addresses patient perceptions regarding pain control, activity level, psychologic symptoms, and somatic symptoms. Each item has a possible score of 0 (no symptom or pain) to 10 (worst).

Data analysis included 99 patients, 57 who underwent radical prostatectomy and 42 who underwent nephrectomy. Investigators compared scores for patients who received opioid prescriptions at discharge and those who did not.

The results showed no significant difference for any pain, activity, or somatic (nausea, drowsiness, itchiness, or dizziness) outcome according to the type of pain management after prostatectomy or nephrectomy. The only significant (P<0.05) difference was greater patient-reported anxiety in the prostatectomy subgroup. Scores for other psychologic symptoms (depression, fright, helplessness) did not differ for the prostatectomy or nephrectomy groups.

“The majority of patients can have adequate pain control without opioids after prostatectomy and nephrectomy,” said Jacobs. Most of our patients were discharged with some combination of [acetaminophen] and ibuprofen. “This is evidence for minimal to no opioid use for other major abdominal surgeries. We are looking into this in our cystectomy population. I think this provides some evidence for other specialties, like general surgery, to think about alternative pathways for their abdominal surgeries.”

The study of an opiate-free pathway for patients undergoing ureteroscopy also had a primary objective of PROs, as assessed by the Patient-Reported Outcomes Measurement System. Patients completed the questionnaire preoperatively, postoperative day 7-10, and 4 to 6 weeks after the procedure, said Ivan Rakic, a research assistant at the University of Michigan Medical Center in Ann Arbor.

Data analysis included 104 patients, 84 with opiate-free pain management and 20 who received opiates after ureteroscopy. The type of pain management was left to the discretion of the surgeon. The patients had a mean age of 54, and kidney stone size averaged a little more than 7 mm. Stone location was more often in the kidney among patients who received opiates (55% vs 43%).

Patients who received opiate-free pain management reported significantly less pain on postoperative days 7 to 10 (P=0.029). Pain intensity scores were similar at baseline and at 4 to 6 weeks, and pain interference scores were similar at all three assessments.

“Our research shows that an opiate-free pathway does not negatively impact patient-reported outcomes, and pain intensity scores may have even been improved,” said Rakic. “Overall, an opiate-free pathway does not seem to worsen the patient’s quality of life. Our work is still underway, and we are cautiously optimistic about results, and are excited for further utilization of validated instruments to gain insight into the patient experience following ureteroscopy for kidney stones.”