New England Section of the American Urological Association

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A Retrospective Evaluation of a Novel Perioperative Opioid Sparing Protocol for Patients Undergoing Robotic Assisted Laparoscopic Surgery
Joseph F. Renzulli, MD1, Henry Cabrera, MD2, Lisa Rameaka, MD2, Christina Procaccianti, PharmD3, David Krok, PharmD4
1Yale, New Haven, RI, 2South County Hospital, Wakefield, RI, 3South County, Wakefield, RI, 4URI, Kingston, RI

Background: The over prescribing of opioid analgesics by health care providers has significantly contributed to the opioid epidemic. The number of individuals addicted to prescription pain medications and the gateway these medications provide to illicit drug use is profound.Over 11 million people abused prescription opioids and more than 40% of all opioid overdose deaths involved a prescription opioid in 2016. Providers were inaccurately educated that patients who have had surgery cannot over utilize these medications, and superior pain control in the post-operative period could improve healing. We now recognize that a multifactorial approach to pain control is far more effective and can enhance earlier recovery after surgery. The negative effects of opioids on cognition, respiratory effort, gastrointestinal and urinary function, and their addictive potential are now common knowledge. Our study purpose is to provide a retrospective evaluation of a non-opioid perioperative regimen for robotic assisted laparoscopic prostatectomy and partial/total nephrectomy patients. Materials and Methods: This study design was a retrospective chart review between patients who received an opioid sparing packet and those who did not. Data was collected from the medical records of 55 consecutive patients who had a robotic assisted laparoscopic surgery performed by the same surgeon at the same facility. Patient data was collected from the inpatient medical record as well as outpatient 7 day post-operative phone calls. The patients length of stay, analog pain scores, number of narcotic tablets utilized in the post-operative period, and the presence of a narcotic prescription at discharge were collected. The statistical significance threshold was set at p-value 0.05 using 95% confidence intervals (CIs). All data was analyzed using Microsoft Excel 2010 software. A paired T-test assuming equal variances was used to compare the differences in length of stay, average pain scores on post day 0, 1 and 2, pain scores 7 days post-op, average oral milligram morphine equivalents and number of narcotics prescriptions. Results: Of 16 traditional patients that did not receive an opioid sparing pathway, 7 (43.75%) were discharged with a narcotic prescription compared to 2 (5.13%) of 39 patients on the opioid sparing pathway that were discharged with a narcotic prescription (p< 0.001). There was no statistically significant difference for the non-opioid sparing versus the opioid sparing patients in hospital length of stay or average analog pain scores on post-operative day 0, 1 and 2. The difference in total oral milligram morphine equivalents was (45.69 vs 29.86, p=0.14) in patients with no history of opioid abuse. Average pain score at home was statistically significant (5 vs 1.8, p<0.001) but the sample size in the non-opioid sparing group was low (n=4) compared to the opioid sparing group (n=30). Conclusion: This novel opioid sparing perioperative regimen can result in the same post-operative pain control and 95% fewer narcotic prescriptions being written at the time of discharge. By decreasing the number of patients requiring narcotics post operatively and decreasing the total number of narcotic prescriptions written, there is the potential to have a positive impact on the opioid epidemic.


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