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2019 ASCO: Pain Management Program for Patients Undergoing Robotic Urologic Surgery

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Key Points

  • Out of 170 patients in the program between September 2018 and January 2019, 115 (68%) were discharged without prescriptions for opioids.
  • A total of 41 patients (24%) went home with 10 pills of the nonnarcotic tramadol, and only 14 (8%) were prescribed 10 pills of oxycodone.

A specialized pain management program for patients who underwent robotic surgery for urologic cancers resulted in 8% of patients going home with narcotics after discharge, compared to 100% who would have received them without this enhanced recovery protocol. The group of patients who did receive narcotics went home with fewer pills than they would have under regular guidelines. These findings were presented by Talwar et al at the 2019 ASCO Annual Meeting (Abstract 6502).

“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,” said lead author Ruchika Talwar, MD, resident in urology at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia. 

Program Details

This study specifically looked at robotic urologic procedures, including radical prostatectomy, radical nephrectomy, and partial nephrectomy. In all of these cases, guidelines indicate sending patients home with varying amounts of oxycodone—between 15 and 45 pills. 

In September of 2018, Penn 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 intravenous dose of ketorolac.

If they were still in pain, patients received tramadol. If complaining of persistent pain despite the standing regimen, patients were given 50 mg or 100 mg of tramadol every 6 hours as needed for a pain level of 5 to 7 or 8 to 10 on the visual analog scale, respectively. If they required further escalation, patients were given 5 or 10 mg of oxycodone every 6 hours as needed on the aforementioned scale. Regardless of escalation status, all patients were discharged on the standing nonnarcotic protocol. If the regimen was escalated, 10 pills of tramadol at 50 mg or oxycodone at 5 mg were prescribed accordingly.

Results

Out of 170 patients in the program between September 2018 and January 2019, 115 (68%) were discharged without prescriptions for opioids. Another 41 (24%) went home with 10 pills of the nonnarcotic tramadol. Only 14 (8%) were prescribed 10 pills of oxycodone.

The study also compared pain scores among patients, and there was no difference among the three groups despite patients receiving different medications. Dr. Talwar said this shows the pain management technique was effective while still recognizing what each patient requires.

“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,” Dr. Talwar explained. “We managed to achieve that while still seeing an overwhelming reduction in the amount of opioids we prescribed.”

Dr. Talwar commented in a press release that this reduction helps more than just the patients, since there are fewer pills in the home and thus fewer pills moving through the community. Researchers also point out that while this model is specific to patients at Penn, the principle is generalizable.

“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,” said senior study author Thomas J. Guzzo, MD, MPH.

Disclosure: For full disclosures of the study authors, visit coi.asco.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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