Key Points

• The opioid prescribing patterns of 13 urologists changed after they participated in a multipronged behavioral intervention.
• The median number of oral morphine equivalents (OMEs) prescribed at hospital discharge decreased from 195 to 19 for prostatectomies and from 200 to 0 for nephrectomies.
• The study's authors are not advocating for the total elimination of opioid prescribing but note that most patients who undergo these 2 procedures will not need opioids after discharge.

According to a new study, a behavioral intervention designed to decrease the amount of opioids that surgeons prescribe achieved that goal and did not adversely affect patient‐reported outcomes.

The research, which focused on patients undergoing prostatectomy or nephrectomy at the University of Pittsburgh in Pittsburgh, Pennsylvania, appears in Cancer (doi:10.1002/cncr.33200).

As gatekeepers of postoperative opioid prescriptions, surgeons can play a sizable role in stemming the country's opioid crisis. However, investigators note that changing physician behavior can be challenging, and how well behavioral science methods work in moving surgeons toward prescribing fewer opioids has been unclear. “This study is the first of its kind to demonstrate a dramatic decrease in opioid prescribing after major surgery, after a behavioral intervention,” wrote the study authors, led by Bruce L. Jacobs, MD, MPH, an assistant professor of urology at the University of Pittsburgh School of Medicine. “We observed a significant decrease in opioid prescribing throughout the department for both prostatectomies and nephrectomies.”

Study Details

The study examined the extent to which medical education, individual‐level feedback, and peer comparison feedback might reduce the postdischarge prescribing of opioids to patients after prostatectomy or nephrectomy. Approximately 382 patients who underwent prostatectomy and 306 patients who underwent nephrectomy were included in the study. The procedures were performed between November 2018 and July 2019 by any of 13 urologists from the university's academic department with either open or minimally invasive procedures.

The study consisted of 3 phases. During pre‐intervention, which occurred over a 4‐month period before the intervention, investigators collected the baseline opioid prescribing data. The second phase, a 6‐month period, covered the behavioral intervention. The third, or washout phase, covered the 3 months of post‐intervention data collection.

The primary outcome that the researchers investigated was the quantity of opioids prescribed in OMEs after patients were discharged. “We converted the number of opioid pills prescribed into OMEs by using the morphine conversion factor provided by the Centers for Medicare and Medicaid Services, which accounts for variation in opioid concentrations in pills,” they wrote.

Of the 382 prostatectomies, 120 were in the pre‐intervention phase, 178 were in the intervention phase, and 84 were in the washout phase. Of the 306 patients who received a nephrectomy, 92 were in the pre‐intervention phase, 142 were in the intervention phase, and 72 were in the washout phase.

The primary exposure was a multifactor behavioral intervention to decrease opioid prescribing. The intervention included 3 components:

• Formal education: Researchers gave a grand rounds presentation to the majority of urology residents and attending surgeons that covered risks of patients becoming chronic opioid users and possible alternative pain management choices.
• Individual audit feedback: A principal investigator sent text messages and emails to participating urologists based on individual results during the preceding month to serve as reinforcement.
• Peer comparison performance feedback: Monthly reports that listed the quantity of opioids each urologist prescribed in comparison with the quantities prescribed by the other surgeons in the study were distributed to the department.

The researchers also assessed patients' perceptions about their postoperative pain management as a secondary outcome with the International Pain Outcomes questionnaire, which was administered 2 weeks after surgery. The questionnaire addressed several aspects of postoperative pain management, including perceived pain control, activity level, and psychiatric and somatic symptoms scored on a scale ranging from 0 (no symptoms) to 10 (severe symptoms).

Study Results

The researchers found that the median OMEs prescribed by surgeons decreased significantly between the pre‐intervention and intervention phases and between the pre‐intervention and washout phases for both prostatectomy patients (from 195 to 19; P = .01) and nephrectomy patients (from 200 to 0; P = .01).

They found no difference in the median OMEs prescribed between the intervention and washout phases for either procedure (P > .05 for both), and this indicated the durability of changes in prescribing behavior.

By the conclusion of the study, the researchers found that the attending surgeons were prescribing 0 opioids for 40% of the prostatectomy surgeries and for 60% of the nephrectomy surgeries. Overall, by the end of the study time frame, the researchers reported that the median number of OMEs prescribed decreased from 195 to 19 for prostatectomies and from 200 to 0 for nephrectomies.

However, the study authors were quick to point out that they are not advocating for completely avoiding opioid prescriptions for all patients after discharge. “Some patients,” they wrote, “such as those with prior opioid use, may require opioids. However, the majority of patients will not need opioids after discharge.”

They added that they found it reassuring that patients who underwent prostatectomy and nephrectomy and were discharged without opioids reported pain control similar to that of patients discharged with opioids.

They also reported that patients discharged with or without opioids reported similar pain management, activity levels, psychiatric symptoms—other than increased anxiety in patients who underwent prostatectomy and were discharged with opioids—and somatic symptoms. “This supports the notion that the majority of patients can have adequate pain control with a non‐opioid pain regimen upon discharge.”

In an accompanying editorial in the same issue of Cancer (doi:10.1002/cncr.33199), 3 surgeons from the Department of Urology at the University of Wisconsin in Madison say that the study “provides one of the most effective single‐institution examples of engaging surgeons in opioid stewardship after major surgery.”

Emily C. Serrell, MD, Caprice C. Greenberg, MD, MPH, FACS, and Tudor Borza, MD, MS, wrote that there are 2 key factors that make this study stand out. “[Researchers] underscore the degree to which surgical opioid prescribing is driven by surgeon behavior rather than patient need, and they demonstrate the effectiveness of non‐opioid regimens for treating surgical pain, even after what are historically considered painful major surgeries.”

However, they added, “The success of this intervention was predicated on provider access to meaningful, granular prescribing data at an individual and department level. These types of data are largely absent at the state or national levels, and even when present, these data are often shown in aggregate across a surgeon's panel of patients and represent many heterogeneous procedures; this makes interpretation and practice change difficult. This is a likely reason behind the disappointing effects of policy interventions and a barrier that will need to be addressed.”

The surgeons added that it is crucial for surgeons to admit to their responsibility in combating the opioid epidemic while promoting interventions “that are scalable across geographic areas and surgical specialties. This will require surgeon engagement locally, regionally, and nationally.”

Photo credit: Roel Smart

中文翻译：

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行为干预改变泌尿科医生的阿片类药物处方实践

关键点

• 在参与多管齐下的行为干预后，13 名泌尿科医生的阿片类药物处方模式发生了变化。
• 出院时开出的口服吗啡当量 (OME) 的中位数从前列腺切除术的 195 减少到 19，肾切除术的从 200 减少到 0。
• 该研究的作者并不主张完全取消阿片类药物处方，但注意到大多数接受这两种手术的患者在出院后不需要阿片类药物。

根据一项新研究，旨在减少外科医生开出的阿片类药物数量的行为干预实现了这一目标，并且没有对患者报告的结果产生不利影响。

该研究的重点是宾夕法尼亚州匹兹堡匹兹堡大学接受前列腺切除术或肾切除术的患者，发表在癌症杂志上(doi:10.1002/cncr.33200)。

作为术后阿片类药物处方的看门人，外科医生可以在遏制该国的阿片类药物危机方面发挥重要作用。然而，研究人员指出，改变医生的行为可能具有挑战性，而且行为科学方法在促使外科医生开出更少的阿片类药物方面效果如何尚不清楚。“这项研究是同类研究中首次证明大手术后和行为干预后阿片类药物处方显着减少，”研究作者写道，该研究由医学博士、公共卫生硕士、医学博士布鲁斯 L.匹兹堡大学医学院。“我们观察到整个部门的前列腺切除术和肾切除术的阿片类药物处方显着减少。”

学习详情

该研究检查了医学教育、个人层面的反馈和同行比较反馈可能会在多大程度上减少前列腺切除术或肾切除术后患者的阿片类药物处方。该研究包括大约 382 名接受前列腺切除术的患者和 306 名接受肾切除术的患者。这些手术是在 2018 年 11 月至 2019 年 7 月期间由该大学学术部门的 13 名泌尿科医生中的任何一位进行的，采用开放式或微创手术。

该研究包括3个阶段。在干预前 4 个月的干预前期间，研究人员收集了基线阿片类药物处方数据。第二阶段，为期 6 个月，涵盖行为干预。第三个阶段或洗脱阶段涵盖了干预后 3 个月的数据收集。

研究人员调查的主要结果是患者出院后 OME 中开出的阿片类药物的数量。他们写道：“我们通过使用医疗保险和医疗补助服务中心提供的吗啡转换因子，将处方的阿片类药物药丸数量转换为 OME，该因子解释了药丸中阿片类药物浓度的变化。”

在 382 例前列腺切除术中，120 例处于干预前阶段，178 例处于干预阶段，84 例处于冲洗阶段。在接受肾切除术的 306 例患者中，92 例处于干预前阶段，142 例处于干预阶段，72 例处于冲洗阶段。

主要暴露是一种多因素行为干预，以减少阿片类药物的处方。干预包括 3 个组成部分：

• 正规教育：研究人员向大多数泌尿外科住院医师和主治外科医生进行了一次盛大的演讲，介绍了患者成为慢性阿片类药物使用者的风险以及可能的替代疼痛管理选择。
• 个人审核反馈：主要调查员根据前一个月的个人结果向参与的泌尿科医生发送短信和电子邮件，以作为补充。
• 同行比较绩效反馈：每月报告列出每位泌尿科医生开出的阿片类药物的数量与研究中其他外科医生开出的数量进行比较，并分发给该部门。

研究人员还使用国际疼痛结果问卷评估了患者对其术后疼痛管理的看法，并将其作为次要结果，该问卷在手术后 2 周进行。问卷涉及术后疼痛管理的几个方面，包括感知疼痛控制、活动水平以及精神和躯体症状，评分范围从 0（无症状）到 10（严重症状）。

研究结果

研究人员发现，对于前列腺切除术患者（从 195 到 19；P = .01）和肾切除术患者（从 200到 0；P = .01）。

他们发现两种手术的干预和冲洗阶段之间规定的中位数 OME 没有差异（两者的P > .05），这表明处方行为变化的持久性。

研究得出结论，研究人员发现，40% 的前列腺切除术和 60% 的肾切除术，主治外科医生开出的阿片类药物为 0。总体而言，在研究时间框架结束时，研究人员报告说，前列腺切除术的 OME 中位数从 195 减少到 19，肾切除术从 200 减少到 0。

然而，研究作者很快指出，他们并不主张在所有患者出院后完全避免使用阿片类药物。“一些患者，”他们写道，“例如那些之前使用过阿片类药物的患者，可能需要阿片类药物。但是，大多数患者出院后不需要阿片类药物。”

他们补充说，他们发现接受前列腺切除术和肾切除术且出院时未服用阿片类药物的患者报告的疼痛控制与服用阿片类药物的患者相似，这令人放心。

他们还报告说，出院时服用或不服用阿片类药物的患者报告了相似的疼痛管理、活动水平、精神症状——除了接受前列腺切除术并服用阿片类药物的患者焦虑增加之外——以及躯体症状。“这支持了这样一种观点，即大多数患者在出院时可以通过非阿片类止痛方案获得足够的疼痛控制。”

在同一期《癌症》 (doi:10.1002/cncr.33199) 的一篇社论中，威斯康星大学麦迪逊分校泌尿外科的 3 位外科医生表示，该研究“提供了最有效的单一机构示例之一”在大手术后让外科医生参与阿片类药物管理。”

Emily C. Serrell, MD, Caprice C. Greenberg, MD, MPH, FACS 和 Tudor Borza, MD, MS 写道，有两个关键因素使这项研究脱颖而出。“[研究人员] 强调手术阿片类药物处方在多大程度上是由外科医生行为而非患者需求驱动的，他们证明了非阿片类药物治疗手术疼痛的有效性，即使在历来被认为是痛苦的大手术之后也是如此。”

然而，他们补充说，“这种干预的成功取决于提供者在个人和部门层面获得有意义的、细粒度的处方数据。这些类型的数据在州或国家层面基本上不存在，即使存在，这些数据也经常在外科医生的患者小组中汇总显示，并代表许多不同的程序；这使得解释和实践改变变得困难。这可能是政策干预效果令人失望的一个原因，也是一个需要解决的障碍。”

外科医生补充说，外科医生必须承认他们在抗击阿片类药物流行方面的责任，同时促进“跨地理区域和外科专业可扩展的干预措施”。这将需要外科医生在当地、地区和全国范围内参与。”

照片来源：Roel Smart