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Opioid use and associated patient satisfaction with pain control after common urologic surgeries?
Clemens An, BS, Ethan D. Jones, MPH, Peter Callas, PhD, Kevan M. Sternberg, MD.
University of Vermont Medical Center, Burlington, VT, USA.

Introduction and Objectives:Non-opioid postoperative pathways have been shown to be successful after various urologic surgeries. Success has been based on outcomes showing no increased utilization of healthcare resources when opioids are omitted in the postoperative setting (need for additional pain prescriptions, office calls for concerning symptoms, and ER visits). The patient perspective however has not been reported. Here we evaluate these important measures in patients undergoing endourologic procedures and robotic assisted radical prostatectomy (RARP).Methods:A 2-phased study performed at an academic medical center included a retrospective review of prescribing patterns after 13 surgeries followed by a prospective patient telephone questionnaire. We present a secondary analysis of the 2 most common urologic surgeries included and describe patient reported outcomes including degree of pain control (very well/well/poor/very poor), satisfaction with pain control (very satisfied/satisfied/unsatisfied/very unsatisfied), and actual pain compared to expected pain (more than expected/as expected/less than expected). Opioid prescription and opioid use were recorded. Bivariate analyses were used to compare patients who did and did not use opioids in the RARP cohort while overall trends were reported for the endourologic procedures.Results:Of the 68 patients undergoing endoscopic intervention, 14 (21%) were prescribed an opioid and 6 (9%) reported any opioid use. 58 (85%) reported their pain was very well or well controlled while 9 reported their pain was poorly controlled. 59 (87%) were satisfied or very satisfied with their pain control. 14 patients had more pain than they expected, 22 as expected, and 30 less than expected. (Table 1)
Fifty-three (93%) of the 57 patients undergoing RARP received an opioid prescription and only 23 reported any opioid use. All but one patient reported that their pain was well or very well controlled and almost all (54) of the patients were satisfied with their level of pain control. 36 (63%) reported their pain was less than expected while only 7 (12%) reported it was more than expected. Of the 23 patients requiring opioid use, 7 (30%) reported they were given more opioids than needed. (Table 2)Conclusion:The majority of patients undergoing endourologic procedures do not use postoperative opioids and report favorable outcomes regarding their pain control. Similarly, after RARP, most patients do not use opioids even when they are prescribed, and are satisfied with their pain control. For the minority of patients who used opioids, the question remains whether they were used because they were given or because they were required for pain control. This challenge of identifying which patients require opioids after surgery requires additional future focus and remains a roadblock to a zero- opioid approach for all.

Table 1. Patient Perspective of Cystoscopy/Endoscopy Patients
		No Opioid Use N(%)	Any Opioid Use N(%)	P Value*	N missing
Cystoscopy / endoscopy patients (n=68)		62	6
How well pain controlled	Very well controlled	28 (46%)	2 (33%)	0.33	1
since surgery	Well controlled	26 (43%)	2 (33%)
	Poorly controlled	6 (10%)	2 (33%)
	Very poorly controlled	1 (2%)	0 (0%)
How satisfied with pain	Very satisfied	35 (57%)	2 (33%)	0.07	1
control since leaving	Satisfied	20 (33%)	2 (33%)
Discuss pain management	No	14 (23%)	1 (17%)	1.00	0
pre-op	Do not recall	1 (2%)	0 (0%)
	Yes	47 (76%)	5 (83%)
Actual pain compared to	More than expected	11 (18%)	3 (50%)	0.28	2
expected	As expected	21 (35%)	1 (17%)
	Less than expected	28 (47%)	2 (33%)
After surgery given instructions	Yes	56 (90%)	6 (100%)	1.00	0
on nonopioid pain manage
Nonopioid med used	Yes	15 (52%)	4 (80%)	0.35	34
Acetaminophen	Yes	13 (21%)	3 (50%)	0.14	0
Ibuprofen	Yes	3 (5%)	2 (33%)	0.06	0
Use walking or exercise	Yes	15 (65%)	3 (60%)	1.00	40
After surgery, prescribed	Yes	8 (13%)	6 (100%)	<0.0001	0
opioid
Prescribed right amount	Less than needed	0 (0%)	1 (17%)	0.07	55
of pain pills	Just the right amount	7 (100%)	3 (50%)
	More than needed	0 (0%)	2 (33%)
Prescription = "PRN"	Yes	5 (100%)	5 (83%)	1.00	57

Table 2. Patient Perspective of Prostatectomy Patients
		No Opioid Use N(%)	Any Opioid Use N(%)	P Value*	N missing
Prostatectomy patients (n=57)		34	23
How well pain controlled	Very well controlled	23 (70%)	10 (45%)	0.11	2
since surgery	Well controlled	10 (30%)	11 (50%)
	Poorly controlled	0 (0%)	1 (5%)
	Very poorly controlled	0 (0%)	0 (0%)
How satisfied with pain	Very satisfied	28 (82%)	14 (67%)	0.24	2
control since leaving	Satisfied	6 (18%)	6 (29%)
Discuss pain management	No	1 (3%)	2 (9%)	0.52	0
pre-op	Do not recall	4 (12%)	1 (4%)
	Yes	29 (85%)	20 (87%)
Actual pain compared to	More than expected	4 (12%)	3 (13%)	0.02	0
expected	As expected	4 (12%)	10 (43%)
	Less than expected	26 (76%)	10 (43%)
After surgery given instructions	Yes	34 (100%)	23 (100%)	--	0
on nonopioid pain manage
Nonopioid med used	Yes	32 (94%)	21 (91%)	1	0
Acetaminophen	Yes	32 (94%)	20 (87%)	0.38	0
Ibuprofen	Yes	0 (0%)	2 (9%)	0.16	0
Use walking or exercise	Yes	34 (100%)	22 (100%)	--	1
After surgery, prescribed	Yes	30 (88%)	23 (100%)	0.14	0
opioid
Prescribed right amount	Less than needed	0 (0%)	1 (4%)	0.01	8
of pain pills	Just the right amount	8 (31%)	15 (65%)
	More than needed	18 (69%)	7 (30%)
Prescription = "PRN"	Yes	28 (97%)	22 (96%)	1	5
*P value is based on Fisher''s exact test to compare patients who did and did not use opioids

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