Management of pain is a central concern of physicians and their patients preparing to undergo conventional or minimally invasive procedures. This interview with Benjamin Davies, MD, in the field of urologic surgery explores how surgeons may be proactive in addressing their challenges and responsibilities for helping to mitigate the current opioid addiction crisis and looks toward a future where opiate-free robotic surgery may become the standard of care. Dr. Davies is a professor at University of Pittsburgh School of Medicine, chief of urology at UPMC Shadyside, and program director of the Urologic Oncology Fellowship at UPMC. He has published extensively on several aspects of urology.
David Ambinder, MD: You have published significantly on several topics, including covering opiate trends and opiate-reduction strategies in urologic surgery. Can you tell us some of the motivations that compelled you to pursue research in this arena?
Benjamin Davies, MD: There were many contributing factors. I always tell the story that, when I was in medical school, my best friend died as a result of a drug overdose. I later found out that he was initially introduced to, and became dependent on, opioids after a back injury. I didn’t know at the time that he had any substance abuse disorder.
When I became an attending physician, I already had a research interest in health services. I then read some works by Chad Brummett, who is a professor of anesthesiology and pain specialist at the University of Michigan. He wrote a great article in 2017, published in the Journal of the American Medical Association, on persistent opioid use after surgical procedures. It was then that I became really jazzed about the topic.
I noticed that after robotic surgery, patients were going home with significant doses of oxycodone, and I questioned this practice, asking if it was necessary for 4 tiny incisions. I also practice in a region that has one of the highest overdose rates in the country, where patients frequently share terrible stories about their loved ones dying because of an overdose. All these factors came together to inspire me to research and help change practice patterns.
Can you briefly review some of the major concepts surrounding the harmful effects of opioid use and how surgery contributes to its impact?
The first concept to understand is diversion. Drugs that you give your patients may well have no effect, and they may not directly cause an opiate use disorder. We take for granted that patients will throw away the medication they don’t use, but in fact many patients don’t discard their opiates. Many people who develop substance abuse disorders first obtain the drugs from family members and loved ones. An example of diversion is when a physician gives a pain medication to a patient, and the patient doesn’t take it, but it’s taken by another person living in their home. This could be a child, parent, sibling, housekeeper—anyone with access to the pills. This should be at the forefront of our minds, because that is how substance abuse disorders start in more than 80% of cases. As a surgeon, this is important to know, because you want to avoid giving your patients any more opiates than they need.
The second concept is that persistent opioid use can begin with even a very small prescription of painkillers. Approximately 1% to 1.5% of patients who are drug naïve when they receive a prescription of opiates for 7 days or more will have persistent opioid use 1 year out. So, to summarize, concerns about diversion and persistence are reasons we should be very careful about the drugs we prescribe to our patients.
What role can surgeons play in reducing opiate use?
The role is simply to help reduce it, and there have been inroads made. Several studies in the past few years have indicated that surgeons have radically decreased the amount of pain medications administered to patients. Moreover, there have been many state-led initiatives. In Pennsylvania, for example, you cannot prescribe more than a set amount of medication to patients undergoing specific surgeries without requesting approval. However, if you dig deep using large insurance-based databases, use of opiates by urologists is still higher than it ought to be. So, we can’t just rest on our laurels and say, “the AUA put out a position paper, we are good now.” Penetration [of ideas] in medicine is very challenging. We must keep hammering the message home, and eventually we’ll get somewhere.
As early as 2019, you began discussing the idea of opiate-free robotic surgery. It was an even more novel concept then than it is now. What is the typical pain regimen you currently prescribe for patients receiving robotic surgery?
That’s simple and straightforward. Preoperatively, patients receive a paravertebral block, gabapentin, and intravenous (IV) anesthesia. Postoperatively, lidocaine is administered around just the incisions, which may be overkill because they have a block anyway, and patients are given 1 full dose of IV ketorolac (Toradol®) as they are waking up. Acetaminophen (preferably administered IV, if possible) and ketorolac are given for the first 6 hours. Oral ibuprofen and acetaminophen are then given after the first IV doses. Of course, if patients continue to experience pain, IV morphine can be dosed in small quantities, if necessary. Most patients are accepting of the typical regimen if it is explained to them beforehand. It is important to counsel patients before surgery and discuss expectations, including what to expect in terms of pain and pain control.
If patients have a history of chronic pain issues, we usually consult chronic pain specialists and consider stronger opiates, if necessary. However, this is rare. It’s important to mention that if patients are taking opiates chronically, we continue their current pain regimen. We’re not here to change their pain regimen.
How would you respond to physicians who are uncomfortable prescribing ketorolac in the immediate postoperative period?
I have reviewed the urology data ad nauseam, and I have yet to see any convincing evidence that it’s going to harm the patient. For the most part, in patients with normal kidney function undergoing a robotic prostatectomy, a full dose of ketorolac is fine. I have never had a patient experience a bleeding problem.
What do you think are some barriers to surgeons implementing opiate-reducing strategies in practice?
There are several significant barriers to change. Of course, there is always physician education, but I think we do a good enough job with new trainees in terms of creating awareness. I think many surgeons become comfortable with the approaches they have used for many years. This contributes to inertia. They may think they have been giving great care for many years, and that it has worked, so deviating away from their standard approach would result in worse quality of care. This means there may be little incentive to make a change. I think continuing discussion and implementing practice-changing policies may help many physicians revise their approaches for the better.
What would you most like to see altered in the next 10 years in terms of how we think about postoperative pain management?
I believe that changes may be industry driven. Pain management is a billion-dollar industry. There is a lot of research investigating narcotic antagonists that do not have addictive potential, and therefore cannot be abused. There already are products evolving around this space. I suspect that several of these agents will become available in the next few years.
Are there any publications you would recommend as reading for someone interested in learning more about the topic?
I believe the best article is the American Urological Association position paper on opioids that was released last year, written by a task force led by Dr. Jennifer Robles.1 It has everything in it. It goes through all the data and really looks at specific details that are important to review, including several aspects we have discussed, such as optimal pain management strategies and questions about ketorolac and bleeding risk. For anyone who is interested, it’s an excellent readily available resource to explore.
- Robles J, Abraham NE, Brummett C, et al; for the American Urological Association. Rationale and strategies for reducing urologic post-operative opioid prescribing. https:// www.auanet.org/documents/Guidelines/White%20Papers/Rationale%20and%20 Strategies%20for%20Reducing%20Urologic%20Post-Operative%20Opioid%20 Prescribing%20unabridged%20version.pdf. Accessed June 20, 2022.