A specialised pain management program for patients who underwent robotic surgery for urologic cancers resulted in just 8% going home with narcotics after discharge, compared with 100% who would have received them without this enhanced recovery protocol.
What’s more, the group of patients who did receive narcotics went home with fewer medications than they would have under regular guidelines.
The findings will be presented on May 31 at the 2019 Annual Meeting of the American Society of Clinical Oncology Annual Meeting (ASCO).
“The key to our program was to start patients with over the counter medications, then escalate them as needed,” said lead author Ruchika Talwar, MD, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. “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.”
This study specifically looked at robotic urological procedures, including radical prostatectomy and both radical nephrectomy and partial nephrectomy. In all of these cases, guidelines indicate sending patients home with varying amounts of oxycodone, between 15 and 45 tablets.
In September 2018, the researchers began a new program that started patients without narcotics and escalated only if needed. Patients received gabapentin and acetaminophen before surgery, then received the drugs again every 8 hours after surgery, along with an IV dose of ketorolac. If they were still in pain, patients received tramadol. Only after all of that were they escalated to oxycodone for their pain. If pain still continued, they were prescribed 10 oxycodone tablets only.
Out of 170 patients between September 2018 and January 2019, 115 (68%) were discharged without prescriptions for opioids. Another 41 (24%) patients went home with 10 tablets of tramadol. Just 14 (8%) were prescribed 10 tablets of oxycodone. The study also compared pain scores among patients, and there was no difference among the 3 groups despite patients receiving different medications.
“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,” said Dr. Talwar. “We managed to achieve that while still seeing an overwhelming reduction in the amount of opioids we prescribed.”
“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 centres may want to implement something like this,” said senior author Thomas J. Guzzo, MD, University of Pennsylvania.