Introduction:

Opioids are routinely overprescribed after surgery, and their use has not significantly decreased after adoption of minimally invasive techniques. For previously opioid-naïve patients who receive opioids after major or minor surgery, over 6% become chronically opioid dependent. In an era of increasing drug addiction and overdose surgeons are gatekeepers to the opioid epidemic. We have a responsibility to our patients to be stewards of appropriate post-operative opioid use.  Over 90,000 robotic assisted laparoscopic prostatectomy (RALP) surgeries are performed annually in the United States. We sought to explore the feasibility of an opioid-free protocol at discharge for patients undergoing RALP at a single academic institution.

Methods:

In July 2019, we initiated an opioid-free protocol consisting of multi-phase interventions in the clinic, pre-operative staging area, operating room, post-operative recovery, and at discharge (Figure 1). Data were prospectively collected on morphine equivalent doses (MED) prescribed at discharge, opioid type, post-operative phone calls, clinic visits, and emergency room (ER) visits related to pain. The prospective cohort was compared to a historical control cohort managed according to individual surgeon preferences. Patients with a history of chronic opioid use or GFR <60 mL/min were excluded. Patient characteristics were compared using the Mantel-Haenszel chi-square test for trend and analysis of variance.  

Results:

65 patients who underwent RALP from October 2017 through January 2018 comprise the historical control cohort. Comparing this historical group to the 12 eligible patients that underwent RALP since institution of the protocol, there were no differences in patient demographics (age, p=0.97; BMI, p=0.25; ASA, p=0.69; history of chronic pain, p=0.326; prior abdominal/hernia surgery, p=0.39; pathologic stage, p=0.69,). Among the historical cohort, mean amount of opioids prescribed at discharge was 163 morphine equivalent doses (MED), compared to 20 MEDs in the intervention group. After initiation of the opioid-free protocol, 2 patients (17%) received a narcotic prescription at discharge.  There has been no increase in the number of pain-related phone calls to the clinic after surgery (2 after initiation of the opioid-free pathway versus 8 in the control group, (p=0.66)). None of the patients in the intervention group required a subsequent opioid prescription, an additional clinic visit, or ER visit related to pain.  

Conclusion:

These preliminary data suggest that institution of an appropriate multi-modal pain management protocol can result in rapid decrease in opioid over-prescription.  Patients undergoing RALP can be discharged without an opioid without compromising patient experience with no significant increase in post-operative phone calls, clinic visits, or ER visits.  

Funding: n/a