Opioid Minimization Protocol for Urologic Robotic Surgery Patients - Aaron Laviana
January 18, 2024
Aaron Laviana discusses a study on reducing opioid use after robotic urologic surgery in a safety-net hospital. The study introduces a simplified opioid minimization protocol, combining non-opioid medications and a Transversus Abdominis Plane (TAP) Block, and evaluates its effectiveness in pain management and patient satisfaction. The protocol includes acetaminophen, ibuprofen, cyclobenzaprine, and TAP Block, with oxycodone and morphine as backup options for uncontrolled pain. The study compares pre- and post-intervention data, showing a significant reduction in opioid use without compromising pain scores or patient satisfaction. The protocol proves to be effective, easy to adopt, and suitable for diverse healthcare systems. Dr. Laviana emphasizes the importance of preoperative counseling and setting patient expectations, highlighting the ongoing relevance of addressing the opioid epidemic in surgical care.
Biographies:
Aaron Laviana, MD, MBA, Assistant Professor of Surgery, The University of Texas at Austin, Dell Medical School
Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
Biographies:
Aaron Laviana, MD, MBA, Assistant Professor of Surgery, The University of Texas at Austin, Dell Medical School
Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
Read the Full Video Transcript
Ruchika Talwar: Hi, everyone, and welcome back to UroToday's Health Policy Center of Excellence. I'm joined by Dr. Aaron Laviana, a urologic oncologist at the University of Texas, Austin, who will be spending some time with us discussing his recent work on reducing opioid prescribing after urologic surgery. Thanks, Dr. Laviana, for being here with us.
Aaron Laviana: Absolutely. It's my pleasure and nice to connect with everybody. Hi, everyone. So the title of our project is Decreased Opioid Use and Equivalent Pain Score Outcomes After Urologic Robotic Surgery in a Safety Net Hospital. So as most of you know, there's still a plague in the United States and abroad of the prescription of excess opioids after surgery. And despite numerous attempts to curb opioid prescriptions, oftentimes these protocols are complex and/or difficult to implement. As a result, we took it upon ourselves here to basically implement a simplified version of an opioid minimization protocol after robotic urologic surgery, and in addition, assess its effectiveness both from a pain standpoint and a patient satisfaction standpoint in a safety-net hospital.
So before engaging in this, we wanted to first see what the patterns were, and so we wanted pre-intervention data here to sort of understand where the pain and problem points were, and then we introduced this minimization protocol. This essentially involved acetaminophen, ibuprofen, cyclobenzaprine, or a muscle relaxant in a Transversus Abdominis Plane or TAP Block. We then collected post-intervention data, and then we administered a validated brief pain inventory survey, first validated in the orthopedic literature, on postoperative day two and day seven. And so for this project here at our institution, we assessed all urologic patients who underwent robotic surgery from January to October of 2021. There were 47 patients in our pre-intervention arm and then 56 in our post-intervention. Along these lines, we excluded patients who had chronic opioid use, who didn't undergo a TAP block. Even though I can get into it, we subsequently did a sensitivity analysis with those patients and then also looked at those patients who didn't fill out a survey response. And then looking at this, we had 35 in the pre-intervention sample and 45 in the post-intervention study sample.
So this is a whole sort of description of what our protocol entails here, and I just want to focus on this dark green box here about the discharge medications, because there was a mix of our patients who went home with same-day surgery and also a mix who stayed one night in the hospital. And so all patients were discharged on acetaminophen or Tylenol, a thousand milligrams every eight hours, ibuprofen, 600 milligrams every eight hours, and cyclobenzaprine, five milligrams every eight hours. We didn't want to have to mix it up and say, "Take one medication at 12, another one at three, another one at six," because we just felt like that overcomplicated things. And we wanted patients just to know they had to take these medications three times a day.
While they were in the hospital, if they had uncontrolled pain, we didn't want anyone to suffer and so we still offered oxycodone, five milligrams PO, every eight hours for a maximum of two doses in morphine only as a third line. And then in the boilerplate, we changed the dose of Tylenol for those with cirrhosis or liver injury, and we avoided ibuprofen for certain factors as well. And so when looking at pre- and post-intervention data here, if you look at the inpatient and outpatient opioid use in the pre-intervention or the blue boxes here, there was markedly higher use of morphine mill equivalents in the pre-intervention arm versus those in the post-intervention. And this is stratified by both prostatectomy and radical and partial nephrectomies. And furthermore, if you look at pain scores on postoperative day two and postoperative day seven, there was no meaningful difference between our intervention arms.
We wanted to look at days two and seven because of the patients were getting the TAP block and we wanted to make sure that this was sustained throughout. And then also looking at other demographics such as walking interference scores, there was no statistical difference between either of the intervention arms. This is looking at our entire brief pain inventory here, and you can see that we looked at interference with general activity, mood, walking, sleep, enjoyment of life. And essentially on day two, there was no difference in outcomes. There was a slight difference in outcomes with mood, but that was essentially it here. And so with this, we can prove that the simplified opioid minimization protocol can decrease outpatient prescriptions without affecting satisfaction or pain.
And most importantly, we wanted to make sure it was easy to adopt and that it's well-suited for any healthcare system. In particular, in our healthcare system, one-third of patients are either uninsured or on Medicaid, one-third are on Medicare, and one-third have private insurance. We have about 20 to 30% of the Hispanic population where English is not their first language, and so we just wanted to make sure that no matter the patient's background or demographic, it was easy to use without affecting their overall pain or satisfaction.
Ruchika Talwar: Thanks, Dr. Laviana. I think the study is really practical and, most importantly, very easily reproducible in the community for all sorts of urologic practices. And I think that's been the biggest barrier historically to opioid reduction. I think when you have a very complex protocol, one can even argue the TAP block perhaps could be a barrier in some cases, but at minimum, implementing your non-opioid protocol and having that escalation option is certainly something that could be adopted in many different practice settings. I'm curious, tell me a little bit more about the TAP block? Can you go into detail about how that's performed, when that's performed, and who does that?
Aaron Laviana: Yes. So with the TAP block or transversus abdominis block, this is given by... for robotic cases, it's given by the anesthesiologist. When we do it open, the urologists do it themselves. But we've changed this throughout and found out that it actually worked best to give it at the start of the case before insufflation because if you give the block at the end of the case, the planes are so distorted that it's often more difficult for everyone to know if they're getting it in the correct space. Theoretically, this block lasts up to 36 hours as well, so it gives a sustained benefit. But for that reason, we also wanted to test these satisfaction and pain scores at day two and day seven to make sure that this wasn't just the TAP block having a sustained effect.
And there's also a push in our practice to go more and more towards same-day surgery as well. So it's one thing to minimize opioids and to send a patient home, but we wanted to make sure that no one was suffering out there once we sent them home because it's very feasible to say, "Okay, you're going home," but if they're in more pain or weren't happy, have we really done any good service here? And so that was a very important point for us to make sure we weren't adversely affecting any of these patients.
Ruchika Talwar: Yeah, I think that makes a lot of sense. And I do think that's one reason why people tend to give at least just a few opioid pills just as sort of a safety blanket because they certainly don't want the patient to be in pain. It can often be difficult to reach their urologist or any provider, particularly now with all these strict laws in place that sometimes limit methods of prescribing. It's not as easy as simply calling a medication in. So I think, like I mentioned before, that escalation piece is really integral. Now, I want to ask, can you tell us how you approach your preoperative counseling? Because although we didn't cover that much in the overview you gave, I think that is an important piece in terms of expectation setting and letting the patient know that perhaps they may not be getting opioids as a first-line method of pain control.
Aaron Laviana: Definitely. A couple of pieces here. One is to track the opioids too and see how many they were taking and what patients were feeling. Like you said, it is getting harder and harder to prescribe these opioids. There is a Texas Prescription Monitoring Program that has this all laid out very well. And so it was very easy for us to track actually who was getting prescribed these opioids, who was filling them, to make this more durable. With regard to the pre-op counseling, you hit the nail on the head there. I think so much of this has to do with that counseling and just setting the expectations from the get-go as opposed to telling someone they're going to stay three to five days and then all of a sudden telling them that they're going home because many of these patients have pets that they have to arrange for or other family members and things of that nature too.
And then just telling them that... One of the nice parts of having this project done now is when I talk to patients is telling them, "We've done this project. We've been studying this now for three years, and we have durable data." And just giving them that reassurance, I think, goes such a long way now in setting these expectations.
Ruchika Talwar: Yeah. And I want to remind our audience, the opioid epidemic is far from over. Specifically, after the pandemic, we've seen a steep rise in opioid dependence rates, overdose rates. And so although we have been having these sorts of discussions about curbing the prescribing of opioids after urologic procedures, I think the topic remains of utmost importance. And I hope that Dr. Laviana spending some time with us today sharing his protocol, perhaps can inspire others out in the community doing these surgeries to also consider an opioid-sparing postoperative pain protocol. So thank you so much, Dr. Laviana, for sharing your expertise with us today.
Aaron Laviana: Absolutely. It's been my pleasure. And a part of it too is we wanted opioid minimization. We didn't want to go just opioid-free. We felt like at the end of the day, patient safety, satisfaction, and pain are paramount here, but we've proven we can go a long way. And like you said, the job is far from over.
Ruchika Talwar: Yeah, I mean, you're absolutely right. We never want to try a blanket approach for everyone. Certainly, there will be people who require opioids, and we want to make sure everyone's pain is adequately controlled, but I think this kind of protocol can really curb the amount of unnecessary opioids we're flooding into the community. So again, we appreciate you being here with us. And to our audience, thanks for spending some time with UroToday. We'll see you next time.
Aaron Laviana: My pleasure.
Ruchika Talwar: Hi, everyone, and welcome back to UroToday's Health Policy Center of Excellence. I'm joined by Dr. Aaron Laviana, a urologic oncologist at the University of Texas, Austin, who will be spending some time with us discussing his recent work on reducing opioid prescribing after urologic surgery. Thanks, Dr. Laviana, for being here with us.
Aaron Laviana: Absolutely. It's my pleasure and nice to connect with everybody. Hi, everyone. So the title of our project is Decreased Opioid Use and Equivalent Pain Score Outcomes After Urologic Robotic Surgery in a Safety Net Hospital. So as most of you know, there's still a plague in the United States and abroad of the prescription of excess opioids after surgery. And despite numerous attempts to curb opioid prescriptions, oftentimes these protocols are complex and/or difficult to implement. As a result, we took it upon ourselves here to basically implement a simplified version of an opioid minimization protocol after robotic urologic surgery, and in addition, assess its effectiveness both from a pain standpoint and a patient satisfaction standpoint in a safety-net hospital.
So before engaging in this, we wanted to first see what the patterns were, and so we wanted pre-intervention data here to sort of understand where the pain and problem points were, and then we introduced this minimization protocol. This essentially involved acetaminophen, ibuprofen, cyclobenzaprine, or a muscle relaxant in a Transversus Abdominis Plane or TAP Block. We then collected post-intervention data, and then we administered a validated brief pain inventory survey, first validated in the orthopedic literature, on postoperative day two and day seven. And so for this project here at our institution, we assessed all urologic patients who underwent robotic surgery from January to October of 2021. There were 47 patients in our pre-intervention arm and then 56 in our post-intervention. Along these lines, we excluded patients who had chronic opioid use, who didn't undergo a TAP block. Even though I can get into it, we subsequently did a sensitivity analysis with those patients and then also looked at those patients who didn't fill out a survey response. And then looking at this, we had 35 in the pre-intervention sample and 45 in the post-intervention study sample.
So this is a whole sort of description of what our protocol entails here, and I just want to focus on this dark green box here about the discharge medications, because there was a mix of our patients who went home with same-day surgery and also a mix who stayed one night in the hospital. And so all patients were discharged on acetaminophen or Tylenol, a thousand milligrams every eight hours, ibuprofen, 600 milligrams every eight hours, and cyclobenzaprine, five milligrams every eight hours. We didn't want to have to mix it up and say, "Take one medication at 12, another one at three, another one at six," because we just felt like that overcomplicated things. And we wanted patients just to know they had to take these medications three times a day.
While they were in the hospital, if they had uncontrolled pain, we didn't want anyone to suffer and so we still offered oxycodone, five milligrams PO, every eight hours for a maximum of two doses in morphine only as a third line. And then in the boilerplate, we changed the dose of Tylenol for those with cirrhosis or liver injury, and we avoided ibuprofen for certain factors as well. And so when looking at pre- and post-intervention data here, if you look at the inpatient and outpatient opioid use in the pre-intervention or the blue boxes here, there was markedly higher use of morphine mill equivalents in the pre-intervention arm versus those in the post-intervention. And this is stratified by both prostatectomy and radical and partial nephrectomies. And furthermore, if you look at pain scores on postoperative day two and postoperative day seven, there was no meaningful difference between our intervention arms.
We wanted to look at days two and seven because of the patients were getting the TAP block and we wanted to make sure that this was sustained throughout. And then also looking at other demographics such as walking interference scores, there was no statistical difference between either of the intervention arms. This is looking at our entire brief pain inventory here, and you can see that we looked at interference with general activity, mood, walking, sleep, enjoyment of life. And essentially on day two, there was no difference in outcomes. There was a slight difference in outcomes with mood, but that was essentially it here. And so with this, we can prove that the simplified opioid minimization protocol can decrease outpatient prescriptions without affecting satisfaction or pain.
And most importantly, we wanted to make sure it was easy to adopt and that it's well-suited for any healthcare system. In particular, in our healthcare system, one-third of patients are either uninsured or on Medicaid, one-third are on Medicare, and one-third have private insurance. We have about 20 to 30% of the Hispanic population where English is not their first language, and so we just wanted to make sure that no matter the patient's background or demographic, it was easy to use without affecting their overall pain or satisfaction.
Ruchika Talwar: Thanks, Dr. Laviana. I think the study is really practical and, most importantly, very easily reproducible in the community for all sorts of urologic practices. And I think that's been the biggest barrier historically to opioid reduction. I think when you have a very complex protocol, one can even argue the TAP block perhaps could be a barrier in some cases, but at minimum, implementing your non-opioid protocol and having that escalation option is certainly something that could be adopted in many different practice settings. I'm curious, tell me a little bit more about the TAP block? Can you go into detail about how that's performed, when that's performed, and who does that?
Aaron Laviana: Yes. So with the TAP block or transversus abdominis block, this is given by... for robotic cases, it's given by the anesthesiologist. When we do it open, the urologists do it themselves. But we've changed this throughout and found out that it actually worked best to give it at the start of the case before insufflation because if you give the block at the end of the case, the planes are so distorted that it's often more difficult for everyone to know if they're getting it in the correct space. Theoretically, this block lasts up to 36 hours as well, so it gives a sustained benefit. But for that reason, we also wanted to test these satisfaction and pain scores at day two and day seven to make sure that this wasn't just the TAP block having a sustained effect.
And there's also a push in our practice to go more and more towards same-day surgery as well. So it's one thing to minimize opioids and to send a patient home, but we wanted to make sure that no one was suffering out there once we sent them home because it's very feasible to say, "Okay, you're going home," but if they're in more pain or weren't happy, have we really done any good service here? And so that was a very important point for us to make sure we weren't adversely affecting any of these patients.
Ruchika Talwar: Yeah, I think that makes a lot of sense. And I do think that's one reason why people tend to give at least just a few opioid pills just as sort of a safety blanket because they certainly don't want the patient to be in pain. It can often be difficult to reach their urologist or any provider, particularly now with all these strict laws in place that sometimes limit methods of prescribing. It's not as easy as simply calling a medication in. So I think, like I mentioned before, that escalation piece is really integral. Now, I want to ask, can you tell us how you approach your preoperative counseling? Because although we didn't cover that much in the overview you gave, I think that is an important piece in terms of expectation setting and letting the patient know that perhaps they may not be getting opioids as a first-line method of pain control.
Aaron Laviana: Definitely. A couple of pieces here. One is to track the opioids too and see how many they were taking and what patients were feeling. Like you said, it is getting harder and harder to prescribe these opioids. There is a Texas Prescription Monitoring Program that has this all laid out very well. And so it was very easy for us to track actually who was getting prescribed these opioids, who was filling them, to make this more durable. With regard to the pre-op counseling, you hit the nail on the head there. I think so much of this has to do with that counseling and just setting the expectations from the get-go as opposed to telling someone they're going to stay three to five days and then all of a sudden telling them that they're going home because many of these patients have pets that they have to arrange for or other family members and things of that nature too.
And then just telling them that... One of the nice parts of having this project done now is when I talk to patients is telling them, "We've done this project. We've been studying this now for three years, and we have durable data." And just giving them that reassurance, I think, goes such a long way now in setting these expectations.
Ruchika Talwar: Yeah. And I want to remind our audience, the opioid epidemic is far from over. Specifically, after the pandemic, we've seen a steep rise in opioid dependence rates, overdose rates. And so although we have been having these sorts of discussions about curbing the prescribing of opioids after urologic procedures, I think the topic remains of utmost importance. And I hope that Dr. Laviana spending some time with us today sharing his protocol, perhaps can inspire others out in the community doing these surgeries to also consider an opioid-sparing postoperative pain protocol. So thank you so much, Dr. Laviana, for sharing your expertise with us today.
Aaron Laviana: Absolutely. It's been my pleasure. And a part of it too is we wanted opioid minimization. We didn't want to go just opioid-free. We felt like at the end of the day, patient safety, satisfaction, and pain are paramount here, but we've proven we can go a long way. And like you said, the job is far from over.
Ruchika Talwar: Yeah, I mean, you're absolutely right. We never want to try a blanket approach for everyone. Certainly, there will be people who require opioids, and we want to make sure everyone's pain is adequately controlled, but I think this kind of protocol can really curb the amount of unnecessary opioids we're flooding into the community. So again, we appreciate you being here with us. And to our audience, thanks for spending some time with UroToday. We'll see you next time.
Aaron Laviana: My pleasure.