Escalation protocol discharges most patients without opioids following robotic cancer surgery
CHICAGO — A standard nonopioid analgesia pathway with escalation options enabled most patients to go home without opioids, while still addressing their cancer and surgical pain, following robotic surgery for genitourinary cancers, according to results of a prospective cohort study presented at ASCO Annual Meeting.
“The key to our program was to start patients with over-the-counter medications, then escalate them as needed,” Ruchika Talwar, MD, resident in urology at Perelman School of Medicine at the University of Pennsylvania, said in a press release. “This means patients whose pain can be managed without opioids never end up getting them in the first place, while patients whose pain warrants these prescriptions receive them when needed.”
Data suggest that patients with cancer are 10 times more likely to die of an opioid overdose than the general population. Also, 6% of patients prescribed opioids to manage pain following cancer surgery become addicted to them, according to the release.
Prior to September 2018, when this study began, researchers found that 100% of their patients who underwent robotic radical prostatectomy, robotic radical nephrectomy and robotic partial nephrectomy were discharged with 75 to 337.5 oral morphine mg equivalents (MME) of oxycodone.
Given the national opioid crises and increased attention to prescribing practices, Talwar and colleagues hypothesized that most patients who undergo robotic urologic surgery for cancer — a procedure associated with less pain than open approaches — can be safety discharged without opioids, but with other means of pain management.
Thus, researchers implemented and evaluated a standard nonopioid analgesia pathway with escalation options for 170 patients undergoing robotic radical prostatectomy (n = 87), robotic radical nephrectomy (n = 25) or robotic partial nephrectomy (n = 58) between Sept. 1, 2018, and Jan. 9, 2019.
Patients received 300 mg oral gabapentin and 975 mg oral acetaminophen once preoperatively, followed those same doses every 8 hours and 15 mg IV ketorolac every 6 hours.
If patients experienced persistent pain with this regimen, they received 50 mg of tramadol every 6 hours for pain levels of 5 to 7, and 100 mg for pain levels of 8 to 10.
If patients required additional pain-management escalation, they received 5 mg or 10 mg oxycodone— using the same pain level scale for dosage — every 6 hours.
All patients were discharged with a standing non-narcotic protocol. Patients who required escalated management at home received 10 pills of 50 mg tramadol or 5 mg oxycodone.
Overall, 67.7% of patients went home without any opioids. Another 24.4% were discharged with 10 pills of 50 mg tramadol (50 MME), and 8.2% with 10 pills of 5 mg oxycodone (75 MME).
Multivariable analysis showed older age reduced likelihood of needing opioids at discharge (OR = 0.96; 95% CI, 0.92-0.99).
Researchers also compared patients’ pain scores and observed no difference across the three discharge groups.
Because this model was specific to practices at University of Pennsylvania, it might not be generalizable to other centers, according to the researchers.
Still, the data show this approach can effectively provide individualized pain management.
“There have been calls to go opioid-free, but some patients do need them, and our data indicate that among our patients, everyone’s pain was controlled after surgery,” Talwar said in the release. “We managed to achieve that while still seeing an overwhelming reduction in the amount of opioids we prescribed.” – by Alexandra Todak
Talwar R, et al. Abstract 6502. Presented at: ASCO Annual Meeting; May 31-June 4, 2019; Chicago.
Disclosures: One author reports a consultant/advisory role with Boston Scientific. Talwar and the other study authors report no relevant financial disclosures.