New England Section of the American Urological Association

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Narcotic Use after Robotic Urologic Surgery - Are We Overprescribing?
Joan C. Delto, MD1; Kristian D. Stensland, MD; MPH2; Aaron Berkenwald, MD2; Lauren Dewey, BS1; Kyle McAnally, BS1; Jodi Mechaber, NP1; Analesa Baraka, NP1; Brian Holliday, PA-C1; Alireza Moinzadeh, MD2; David Canes, MD2; Sara Hyde, BS1; Peter Chang, MD; MPH1; Andrew A. Wagner, MD; MPH1
1Beth Israel Deaconess Medical Center, Boston, MA; 2Lahey Medical Center, Burlington, MA

Background:
Overprescription of narcotic pain medications in the post-operative setting has been identified as a significant contributor to our nationwide opioid crisis. In this study, we sought to quantify the level of narcotic overprescription after minimally invasive urologic surgery by assessing narcotic prescription and utilization patterns, and identifying potential risk factors for higher post-operative narcotic use.
Methods:
We prospectively recorded pain pill usage, including narcotics, acetaminophen, and ibuprofen, following robotic radical prostatectomy (RP) and robotic partial nephrectomy (PN) at two academic institutions. At discharge, patients were encouraged to use non-narcotics for first-line pain control, and narcotics for breakthrough pain. All patients completed a pain pill log documenting the daily quantity of pills taken of each analgesic type. At the first post-operative visit, our clinic staff verified patient-reported narcotic utilization by physically counting the remaining narcotic pills. We also recorded potential risk factors for increased narcotic usage -- including age, gender, pre-existing comorbidities, depression, prior narcotic use, and alcohol consumption and used multivariable logistic regression to evaluate the association of these factors with higher narcotic utilization.
Results:
94 RP and 35 PN patients completed their pain pill logs and were included in this study (see table). Most were prescribed 20 to 30 pills of oxycodone 5 mg. 10-15% of patients did not fill their narcotic prescription. For RP patients, 83% of narcotic pills that were filled were unused. PN patients used a higher proportion of their filled narcotic pills, but 66% of pills were unused. If all patients had filled their prescriptions, 2067 (85%) and 647 (70%) of pills after RP and PN, respectively, would have been left unused.
An average of 3.9 and 7.9 narcotic pills per patient were used, with a mean usage duration of 1.9 and 3.7 days after RP and PN, respectively. 43-51% used zero narcotic pills postoperatively.
Only 16/129 (12.4%) of patients required ≥15 narcotic pills. On multivariable analysis, we did not identify any significant predictors of taking > 15 narcotic pills after RP. After PN, younger age (OR 0.62, 95% CI 0.32-0.86, p = 0.046), higher Charlson comorbidity score (OR 7.13, 95% CI 1.83-94.7, p = 0.03), and a higher number of narcotic pills prescribed (OR 1.90, 95% CI 1.22-6.90, p = 0.045) were associated with taking ≥15 narcotic pills post-operatively.
Conclusions:
Narcotic overprescription is common after robotic urologic surgery. The majority of patients following RP and PN require minimal or no narcotics following discharge when first-line use of non-narcotic medications are encouraged. In this small study of 129 patients, more than 2,200 excess, unused narcotic pills were filled. Clinicians should prescribe fewer routine postoperative narcotics, encourage patients to first use non-narcotic pain regimens, and educate patients on proper disposal of excess narcotics. Subsequent studies will evaluate strategies to modify narcotic prescription routines and curb overprescription.
Table: Pain pill usage after robotic urologic surgery

Radical Prostatectomy
n=94
Partial Nephrectomy
n=35
Male sex94 (100%)23 (65.7%)
Mean age (years)62.7 (range 46-85)46.2 (28-80)
Mean BMI28 (range 19-41)29.5 (19-44)
Mean Charlson score (age-adjusted)4.8 (2-7)3.6 (0-8)
Narcotic Use
Total narcotic pills prescribed2420922
# unused prescribed pills (%)2067.5 (85.4%)648 (70.3%)
Prescriptions filled (%)80 (85%)28 (80%)
# unused filled narcotic pills (%)1722.5 (83%)528 (65.6%)
Mean narcotic pills prescribed26.7 (range 20-30)27.1 (range 0-60)
# of patients using post op narcotics (%)47 (50%)19 (54.3%)
# Narcotics pills used (%)0 pills: 48 (51.1%)
<10 pills: 32 (34.0%)
10-20 pills: 10 (10.6%)
≥20 pills: 4 (4.3%)
0 pills: 15 (42.9%)
<10 pills: 10 (28.6%)
10-20 pills: 4 (11.4%)
≥20 pills: 6 (17.1%)
Mean pills used/patient3.9 (range 0-37)7.9 (range 0-38)
Mean days of narcotic use/patient1.9 (range 0-11)3.7 (range 0-18)
Ibuprofen Use
# of patients using Ibuprofen (%)56 (62.8%)20 (57.1%)
Mean ibuprofen pills used/patient7.8 (range 0-45)7.2 (range 0-32)
Mean days of ibuprofen pills use/patient3.3 (range 0-13)4.4 (0-17)
Acetaminophen Use
# of patients using acetaminophen (%)67 (71.3%)22 (88%)
Mean acetaminophen pills used/patient11.3 (range 0-46)24.2 (1-122)
Mean days of acetaminophen used/patient3.7 (range 0-11)8.5 (0-42)

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