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AUA 2019

AUA 2019: Opiate Use after Radical Prostatectomy: The End is Here

Chicago, IL (UroToday.com) Dr. Ben Davies, Professor of Urology at the University of Pittsburgh has become a thought leader with regards to the opioid epidemic and specifically how it pertains to the field of surgery and urology. At the SUO 2019 meeting at the AUA, he discussed opiate use after radical prostatectomy.

Dr. Davies notes that the FDA Commissioner recently stated: “Until clinicians stop prescribing opioids far in excess of clinical need, this crisis will continue unabated.” Indeed, 75% of abused opioids come/stolen from MDs, their friends or relatives. Dr. Davies notes that there have been three waves in the rise in opioid overdose deaths:

  • Wave 1 (starting in 1999): rise in prescription opioid overdose deaths (ie. natural and semi-synthetic opioids and methadone)
  • Wave 2 (starting in 2010) rise in heroin overdose deaths
  • Wave 3 (starting in 2013) rise in synthetic opioid overdose deaths (ie. tramadol and fentanyl)
A study in 2018 analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death.1 Shockingly, the overall 38-year curve is exponential, providing evidence that the current wave of opioid overdose deaths may just be the latest manifestation of a more fundamental longer-term process:

AUA2019_ noopiodradicalprostatectomy_1.png


This is a composite of multiple distinctive subepidemics of different drugs (primarily prescription opioids, heroin, methadone, synthetic opioids, cocaine, and methamphetamine), each with its own specific demographic and geographic characteristics.

Furthermore, Dr. Davies notes that there is new persistent opioid use among opioid naïve patients after undergoing elective procedures:
  • Hepatobiliary: 6%
  • Knee/hip surgery: 8%
  • Hand surgery: 13%
  • Spine surgery: 13%
  • Pediatric surgery: 5%
  • Elective oncology: 10%
Dr. Davies also highlighted that 75% of prescribed opioids in urologic patients are not used. To summarize, his three reasons for no opioid use after radical prostatectomy are:
  • Decrease opioids in our community
  • Decrease persistent opioid use in our patients
  • Decrease massive overprescribing
His “no opioid radical prostatectomy” includes (i) preoperative oral Neurontin, acetaminophen, +/- Celebrex, (ii) a single shot of ropivicaine, decadron, or precedex in the quadratus lumborum, (iii) intraoperative separate infusions of propofol, ketamine, and precedex, (iv) post-operative toradol 15mg IV while in the hospital, followed by Tylenol and motrin for 48 hours
AUA2019_ noopiodradicalprostatectomy.png


Following the implementation of this protocol and a number of “nudges” to his faculty via lectures, guidelines, texts, and emails, Dr. Davies notes that average number of pills prescribed after radical prostatectomy went from 40 prior to implementation down to 2 in February 2019. Furthermore, when evaluating patients with pain/satisfaction surveys, patients were not suffering in pain from the lack of opioids.

Dr. Davies concluded with several take homes messages/”warning facts”:
  • More people died of opioid overdose than prostate cancer last year
  • Persistent opioid use is the #1 “surgical complication”
  • >95% of men require no opioid use for their radical prostatectomy and they should not be ordered routinely

Presented by: Benjamin Davies, Professor at the University of Pittsburgh School of Medicine, Chief of the Urology Section at the Shadyside/Hillman Cancer Center, Director of the Urologic Oncology Program, Pittsburgh, PA

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University - Medical College of Georgia, Twitter: @zklaassen_md at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

References:
  1. Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science. 2018 Sep 21;361(6408).