Preventing Excess Narcotic Prescriptions in New Robotic Surgery Discharges: The PENN Prospective Cohort Quality Improvement Initiative

Purpose: To reduce the amount of opioids prescribed at discharge after robotic surgery, we hypothesized that the majority patients do not require opioids for pain control after robotic urologic oncologic procedures. Materials and Methods: This prospective study aimed to reduce opioids prescribed at discharge after robot-assisted radical prostatectomy (RARP), robot-assisted radical nephrectomy (RARN), and robot-assisted partial nephrectomy (RAPN). Before 9/2018, 100% of patients were discharged on varying amounts of oxycodone (range: 75-337.5 oral morphine milligram equivalents [MME]). We implemented a standardized nonopioid analgesia pathway with escalation options (Fig. 1). To assess the safety of our approach, we analyzed pain scores, telephone encounters, and emergency department visits in our cohort. FIG. 1. PENN QI opioid-free pilot pain management pathway. PENN = preventing excess narcotic prescriptions in new robotic surgery discharges. Results: Our cohort (n = 170) consisted of patients undergoing RARP (n = 87), RARN (n = 25), and RAPN (n = 58) between September 2018 and January 2019. Overall, 67.7% were discharged without opioids, 24.4% with 10 pills of tramadol (50 MME), and 8.2% with 10 pills of oxycodone (75 MME). On multivariable analysis, older age (odds ratio: 0.961, 95% confidence interval: 0.923-0.995, p = 0.026) was associated with lower odds of needing opioids at discharge. There was no difference in pain scores at the postoperative outpatient visit (p = 0.66) or postoperative telephone encounters (p = 0.45) between those discharged with and without opioids. Conclusion: The majority of robotic surgery patients do not require opioids upon discharge. Implementation of a simple, standardized nonopioid protocol resulted in a dramatic reduction in the amount of opioids prescribed in our patient population. An escalation protocol allows for a patient-centered approach to reduce narcotic prescribing, although still addressing surgical pain.