Opioid Overprescription Targeted by New Plans

SAN FRANCISCO — Opioids are being overprescribed by urologists, according to researchers who have proposed new prescribing schedules to reduce the number of tablets that go unused.

"Reducing the opioid oversupply may reduce the epidemic," said Kathryn Hacker, MD, PhD, from the University of North Carolina at Chapel Hill, who was one of three researchers who presented studies on opioid overuse during a press conference here at the American Urological Association (AUA) 2018 Annual Meeting.

About 6% to 10% of patients become persistent opioid users after getting a prescription for pain from surgery, she explained.

In addition, the number of drug-overdose deaths that involve prescription opioids was three and a half times higher in 2016 than it was in 1999, said Matthew Ziegelmann, MD, from the Mayo Clinic in Rochester, Minnesota.

Both Hacker and Ziegelmann used prescription patterns at their institutions to formulate internal guidelines with an eye toward cutting back.

Hacker and her colleagues used CPT codes and the pharmacy database to determine how many of the opioids prescribed by urologists at the University of North Carolina are used.

Of the 606 patients who had undergone surgery and were contacted by the researchers 2 weeks after the procedure, 264 completed a telephone survey about postoperative opioid use and storage and disposal habits.

For every procedure, the average number of tablets used was less than the average number prescribed. Only about one-third of patients received any counseling on how to store or dispose of unused opioids. And only 13% locked them up.

Hacker's team used the data on unused tablets to suggest that urologists prescribe fewer tablets and proposed a standard prescribing schedule for six procedures.

Table 1. Unused Tablets and Proposed Standards

Procedure	Patients, n	Unused Tablets, n	Proposed Schedule (5 mg Oxycodone Equivalent)
Guidelines proposed
Ureteroscopy	47	346	10
Cystoscopy or transurethral resection	73	362	10
Penile or urethral	25	261	20
Lab nephrectomy	40	427	15
Prostatectomy	27	491	20
Cystectomy	11	189	15
No guidelines proposed
Stent	11	33	—
Percutaneous nephrolithotomy	13	125	—
Scrotal or testis	14	72	—
Major oncology	3	55	—

The proposal has not met with much resistance. "The main concern we have heard is whether we're going to be undertreating pain. But for the most part, everyone has been on board," Hacker told Medscape Medical News.

In their study, Ziegelmann and his colleagues looked at prescribing patterns for 21 common urologic procedures in 2015 and 2016.

They identified 9229 patients who were prescribed an opioid at discharge from one of three tertiary care centers. They converted prescriptions to oral morphine equivalents (OME), with 200 OME equaling approximately twenty-six 5 g tablets of oxycodone.

Nearly 80% of patients were prescribed an opioid at discharge, and the median OME prescribed was 187.5 (interquartile range, 150 - 225).

Table 2. Median OME Prescribed

Procedure	Median	Interquartile Range
Open cystectomy	300	225–525
Open radical nephrectomy	300	225–375
Retroperitoneal lymph node	300	225–375
Penile prosthesis placement	225	150–325

The researchers concluded that the variation in prescriptions is unwarranted, and proposed new standards, dividing procedures into four tiers by the proposed maximum OME.

In tier 0 — vasectomy — no opioids are being prescribed, and the team does not recommend any.

In tier 1 — procedures such as cystolitholapaxy and ureteral stent placement — the team proposes a maximum of 50 - 75 OME, rather than the median 100 OME prescribed.

In tier 2 — procedures such as laparoscopic nephrectomy and laparoscopic radical prostatectomy — the team proposes a maximum of 200 OME, rather than the median 225 OME prescribed.

In tier 3 — open radical retropubic prostectomy, radical nephrectomy, partial nephrectomy, and open cystoprostatectomy with ileal conduit or ileal neobladder — the team proposes a maximum of 300 OME, in line with the median 240 - 300 OME prescribed.

"What we did not want to do is come out with guidelines that drastically changed what people were doing," Ziegelmann told Medscape Medical News.

The team is planning to examine the proportion of opioid prescriptions patients are using and how well their pain is controlled. The guidelines will likely be revised once the team has gathered those data, Ziegelmann said.

Both Hacker and Ziegelmann said they recommend that their patients try over-the-counter pain relievers, such as acetaminophen and ibuprofen, before taking opioids.

What we did not want to do is come out with guidelines that drastically changed what people were doing.

Evidence for intravenous ketorolac as monotherapy for kidney stones was presented by Andrew Portis, MD, from the HealthEast Kidney Stone Institute in St. Paul, Minnesota.

Patients prescribed ketorolac alone were less likely than those prescribed a narcotic alone or a narcotic in combination with ketorolac to need rescue medication or to be admitted to the hospital. In addition, hospital stays were shorter for patients prescribed ketorolac alone.

The AUA is working on its first policy statement on opioids use and will be sponsoring a discussion on the topic at its headquarters in Linthicum, Maryland on December 8.

Hacker, Ziegelmann, and Portis have disclosed no relevant financial relationships.

American Urological Association (AUA) 2018 Annual Meeting: Abstract MP80-04. Presented May 18, 2018.

Follow Medscape on Twitter @Medscape and Laird Harrison @LairdH

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.