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Avoiding Narcotics in Post-Surgery Cancer Pain Management

Opioid addiction, which is currently so widespread that it amounts to a national crisis, often starts with the legitimate use of prescription pain medication after surgery or as a result of another medical condition. For this reason, it is essential to develop non-narcotic strategies to handle pain. A team of researchers in the Perelman School of Medicine at the University of Pennsylvania did just that, designing a program that successfully managed post-surgery pain for patients with urologic cancers while dramatically reducing the use of narcotics.

This quality improvement initiative focused on patients undergoing one of three robotic surgeries for urologic cancers: robotic radical prostatectomy (RARP), robotic radical nephrectomy (RARN), or robotic partial nephrectomy (RAPN). Even though robotic urologic surgeries for cancer are known to result in less pain than open surgeries, prior to the beginning of the program, all patients undergoing these surgeries were discharged on varying amounts of oxycodone. The researchers hypothesized that most of these patients could be safely discharged without opioids.

Patients with urologic cancer undergoing RARP, RARN, or RAPN were given 300 mg gabapentin and 975 mg acetaminophen once orally in the pre-operative setting. Following the surgery, they were given 300 mg gabapentin and 975 mg acetaminophen orally every eight hours, along with 15 mg intravenous ketorolac every six hours. Patients who complained of persistent pain in spite of this regimen were given 50 or 100 mg of tramadol, a weak opioid, every six hours as needed for pain, with the dosage depending on the pain's severity. If patients still complained of persistent pain to the point where further intervention was needed, they were given 5 or 10 mg of oxycodone, a stronger opioid, with the dosage depending on the severity of the pain. All patients were discharged from the hospital with the standing non-narcotic protocol; if escalation was needed, patients were prescribed 10 pills of 50 mg tramadol or 10 pills of 5 mg oxycodone.

"The key to our program was to start patients with over the counter medications, then escalate them as needed. This means patients whose pain can be managed without opioids never end up getting them in the first place, while patients whose pain warrants these prescriptions receive them when needed," explained Ruchika Talwar, MD, a urology resident at Penn Medicine and lead author of the study, results of which will be presented at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago.

This approach clearly worked. Of the 170 patients with urologic cancer participating in the initiative, 67.7% were discharged without opioids, 24.4% with 10 pills of tramadol, and 8.2% with 10 pills of oxycodone. Older age was associated with lower chance of needing opioids at discharge.

"There have been calls to go opioid-free, but some patients do need them, and our data indicate that among our patients, everyone's pain was controlled after surgery," commented Dr. Talwar. "We managed to achieve that while still seeing an overwhelming reduction in the amount of opioids we prescribed."

Thomas J. Guzzo, MD, MPH, Chief of Urology at Penn Medicine and senior author of the study, remarked on the implications of the research: "Every practice is different, and so our next goal is to test this approach in a multi-institutional study, but we felt it was important to share our success to start the conversation about how other centers may want to implement something like this."

For More Information

Talwar R, Xia L, Serna J, et al (2019). Preventing excess narcotic prescriptions in MIS urologic oncology discharges (PENN): a prospective cohort quality improvement initiative. J Clin Oncol, 37(suppl). Abstract 6502.

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