A protocol focusing on non-opioid pain control measures, as well as patient education, helped eliminate the need for post-discharge opioid prescriptions after major urologic cancer surgery, according to a cohort study.

Among nearly 650 opioid-naive patients, the rate of opioid prescriptions at discharge was 57.9% for those who received an instruction sheet that explained the rationale for avoiding opioids and using non-opioid medications for postoperative pain control (lead-in group) and 2.2% among those who followed the NOPIOIDS protocol, compared with 80.9% of the control group (Kruskal-Wallis test of medians P<0.001), reported Badar M. Mian, MD, of Albany Medical College in New York, and colleagues.

The overall median tablets prescribed was 4, 0, and 14 per patient in these groups, respectively (Kruskal-Wallis test of medians P<0.001). In the NOPIOIDS (No Opioid Prescriptions at Discharge After Surgery) group, median and mean opioid dose was 0 tablets for all procedure types, except for kidney procedures (mean 0.5 tablets), they noted in JAMA Surgery.

This perioperative protocol “may be safe and effective in nearly eliminating the need for opioid prescriptions after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery,” Mian and team wrote.

In patient-reported assessments, pain scores in the NOPIOIDS group were on the low end (a mean of 2.5 on a scale of 1-10), while patient-reported satisfaction was high (a mean of 86.6 on a scale of 1-100).

Overall 30-day complication rates were similar between the control, lead-in, and NOPIOIDS groups, at 16.3%, 21%, and 17.0%, respectively.

Benjamin J. Davies, MD, chief of urology at the University of Pittsburgh Medical Center Shadyside, told MedPage Today that this study is “another in a long list of nicely performed trials that highlight several points.”

“The vast majority of patients undergoing all forms of urologic cancer surgery do not need postoperative opioids, a fact shown several times before both in formal randomized controlled trials and more interventional-based protocols like this one,” said Davies, who was not involved in the study.

Patient-reported outcomes are usually better in non-opioid groups “largely due to the sedative/depressing effects of narcotics,” he added.

Mian and colleagues also looked at unplanned health utilization among the three groups, and found that 41 telephone calls were made to the office for any reason after discharge in the NOPIOIDS group compared with 34 in the control group (P=0.04), while the number of calls related to inadequate pain control were similar between the control (nine calls), lead-in (two calls), and NOPIOIDS groups (11 calls).

The study cohort included 686 consecutive patients (mean age 63.6, 73.9% men, 90.6% white) at a tertiary care referral center undergoing either open or minimally invasive cancer surgery, including radical cystectomy with urinary diversion, radical or partial nephrectomy, and radical prostatectomy.

The control group included 202 patients treated from May 2017 to December 2018, the lead-in group included 100 patients treated from January to June 2019, and the NOPIOIDS group included 384 patients treated from July 2019 to June 2021.

Baseline patient characteristics, including body mass index, sex, race, length of hospital stay, and preoperative opioid use, were similar among the groups, as was the use of minimally invasive surgery. Thirty-nine patients were using opioids prior to surgery, leaving 647 opioid-naive patients.

Rates of additional opioid prescriptions were similar between the control, lead-in, and NOPIOIDS groups, at 4.1%, 1.1%, and 2.8%, respectively.

Mian and colleagues noted that “systemic factors such as state-mandated education, dose limits, and general awareness about opioids could have influenced the prescribing behavior,” which was a study limitation.

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