Introduction:

More than 40 people die daily from an overdose involving prescription opioids, with over 4 million Americans engaged in non-medical use of prescription opioids each month. Opioid stewardship is therefore essential to help eliminate the crisis, as prescriptions over 50 morphine milligram equivalents per day (MME) increases the risk of overdose by two-fold. Previous studies based off of electronic orders may underestimate opioid usage if patients seek other providers or pharmacies. Little is known about the prescribing practices after prostatectomy and the long-term usage of opioids. Therefore, we sought to characterize existing practice patterns and opioid use characteristics in a large tertiary academic center.

Methods:

After receiving approval from the University of Pennsylvania’s Quality Improvement Institutional Review Board, opioid prescriptions from 1,574 consecutive patients who underwent a radical prostatectomy for localized prostate cancer at a single institution from June 2015 to October 2018 were evaluated utilizing the Pennsylvania Prescription Drug Monitoring Program (PDMP). All drug strengths were converted to MME to facilitate comparison, with 50 MME being roughly equivalent to 10 tablets of Vicodin (5/300). Prolonged opioid use was defined as opioid use for 3 months or more.  

Results:

A median of 210 MME (IQR 210-337.5) were prescribed postoperatively, equaling 52.5 MME (IQR 30-70) per day. More than half of the patients (56%) were prescribed more than 50 MME per day. There was extensive variation in prescribing patterns among different providers, with median values ranging from 42 to 84 MME per day. Overall, 34.2% (447/1308) of the patients were prescribed an opioid at least once before undergoing a prostatectomy, with 3.6% (47/1308) having prolonged use before prostatectomy. After prostatectomy, 5.3% (69/1308) of the patients had prolonged use of opioids. Of the patients who had prolonged use after prostatectomy, 53.6% (37/69) of the patients had their initial opioid exposure with the postoperative prescription. Those with prolonged opioid use after prostatectomy used more pharmacies (median 3, IQR 2-5) than those without chronic use (median 1 (IQR 1-2) to fill the opioid prescriptions (p<0.01). The amount of opioids prescribed daily (MME per day) did not differ according to the patient’s previous opioid exposure (p=0.56) or history of prolonged opioid use (p=0.25). Patient demographic and operative factors, such as age, race, and length of stay, were not associated with prolonged opioid use after prostatectomy.  

Conclusion:

There was a significant quantity of opioids prescribed after prostatectomy, with significant variation among different providers. More than half of the patients using opioids for prolonged periods received their first prescription after prostatectomy. Future studies to improve PDMP surveillance and implementation of non-opioid alternatives would be required to help improve opioid stewardship after prostatectomy.

Funding: N/A