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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)626
How well pain controlledVery well controlled28 (46%)2 (33%)0.331
since surgeryWell controlled26 (43%)2 (33%)
Poorly controlled6 (10%)2 (33%)
Very poorly controlled1 (2%)0 (0%)
How satisfied with painVery satisfied35 (57%)2 (33%)0.071
control since leavingSatisfied20 (33%)2 (33%)
Discuss pain managementNo14 (23%)1 (17%)1.000
pre-opDo not recall1 (2%)0 (0%)
Yes47 (76%)5 (83%)
Actual pain compared toMore than expected11 (18%)3 (50%)0.282
expectedAs expected21 (35%)1 (17%)
Less than expected28 (47%)2 (33%)
After surgery given instructionsYes56 (90%)6 (100%)1.000
on nonopioid pain manage
Nonopioid med usedYes15 (52%)4 (80%)0.3534
AcetaminophenYes13 (21%)3 (50%)0.140
IbuprofenYes3 (5%)2 (33%)0.060
Use walking or exerciseYes15 (65%)3 (60%)1.0040
After surgery, prescribedYes8 (13%)6 (100%)<0.00010
Prescribed right amountLess than needed0 (0%)1 (17%)0.0755
of pain pillsJust the right amount7 (100%)3 (50%)
More than needed0 (0%)2 (33%)
Prescription = "PRN"Yes5 (100%)5 (83%)1.0057

Table 2. Patient Perspective of Prostatectomy Patients
No Opioid Use N(%)Any Opioid Use N(%)P Value*N missing
Prostatectomy patients (n=57)3423
How well pain controlledVery well controlled23 (70%)10 (45%)0.112
since surgeryWell controlled10 (30%)11 (50%)
Poorly controlled0 (0%)1 (5%)
Very poorly controlled0 (0%)0 (0%)
How satisfied with painVery satisfied28 (82%)14 (67%)0.242
control since leavingSatisfied6 (18%)6 (29%)
Discuss pain managementNo1 (3%)2 (9%)0.520
pre-opDo not recall4 (12%)1 (4%)
Yes29 (85%)20 (87%)
Actual pain compared toMore than expected4 (12%)3 (13%)0.020
expectedAs expected4 (12%)10 (43%)
Less than expected26 (76%)10 (43%)
After surgery given instructionsYes34 (100%)23 (100%)--0
on nonopioid pain manage
Nonopioid med usedYes32 (94%)21 (91%)10
AcetaminophenYes32 (94%)20 (87%)0.380
IbuprofenYes0 (0%)2 (9%)0.160
Use walking or exerciseYes34 (100%)22 (100%)--1
After surgery, prescribedYes30 (88%)23 (100%)0.140
Prescribed right amountLess than needed0 (0%)1 (4%)0.018
of pain pillsJust the right amount8 (31%)15 (65%)
More than needed18 (69%)7 (30%)
Prescription = "PRN"Yes28 (97%)22 (96%)15
*P value is based on Fisher''s exact test to compare patients who did and did not use opioids

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