BACKGROUND: Radical cystectomy (RC) often requires a prolonged course of opioid medications for postoperative pain management. We implemented a Reduced Opioid Utilization (ROU) protocol to decrease exposure to opioid medications. OBJECTIVE: To determine the impact of the ROU protocol on opioid exposure, pain control, inpatient recovery, and complication rates among patients who underwent RC. METHODS: The ROU protocol includes standardized recovery pathways, a multimodal opioid-sparing pain regimen, and improved patient and provider education regarding non-opioid medications. Opioid exposure was calculated as morphine equivalent dose (MED), and was compared between RC patients following the ROU protocol and patients who previously followed our traditional pathway. Opioid-related adverse drug events (ORADEs), pain scores, length of stay, and 90-day complications, readmission, and mortality were also compared between cohorts. RESULTS: 104 patients underwent RC, 54 (52%) of whom followed the ROU protocol. ROU patients experienced a statistically significant decrease in opioid exposure in the post-anesthesia care unit (p = 0.003) and during their postoperative recovery (85.7 ± 21.0 MED vs 352.6 ± 34.4 MED, p < 0.001). The ROU protocol was associated with a statistically significant decrease in ORADEs after surgery. There was no significant difference in average pain scores, length of stay, readmissions, or 90-day complication or mortality rates. CONCLUSIONS: The ROU protocol decreased opioid use by 77% without compromising pain control or increasing the rate of complications. This study demonstrates the efficacy of non-opioid medications in controlling postoperative pain, and highlights the role providers can play to decrease patient exposure to opioids after RC surgery.

269 Background: Multiple sources have reported on widespread abuse of opioid pain medications among Americans. For many patients, the first encounter with these addictive substances happens when they are prescribed opioids for acute pain management after surgery. Unfortunately, 6% of opioid-naïve patients become newly addicted to opioid medications after surgery. As a high-volume surgical department, we aimed to reduce our reliance on opioid medications to manage post-operative pain by 50% from a baseline morphine equivalent daily dose (MEDD) of 95.1 to a target of 47.5 MEDD. Methods: We retrospectively reviewed daily opioid use, pain scores, and anxiety scores for inpatients recovering from surgery for urologic cancers at our institution over 4 months. We generated process maps, Ishikawa diagrams, and Pareto charts to identify causes contributing to excess opioid use. We designed opioid-sparing pain regimens (using varying combinations of acetaminophen, ketorolac, gabapentin, and local anesthetic) and we identified key drivers required to reliably decrease excess opioid use. Initial interventions were aimed at educating providers and nurses on availability and efficacy of non-opioid medications and later interventions sought to facilitate adoption of the novel pathways. Results: Over the course of this QI project involving 443 patients, the median opioid use per patient decreased 46% from 95.1 to 51.5 MEDD. This reduction in opioid requirements after implementation was successfully achieved across multiple surgery types ranging from robotic prostatectomy (55.1 MEDD) to open radical cystectomy (50.6 MEDD). There was no increase in 24- or 48-hour post-operative pain score associated with use of opioid-minimizing pathways (3.03 vs. 3.04 and 2.92 vs. 2.96, respectively; p > 0.05 for both). Similarly, there was no change in anxiety score at 24- or 48-hours after surgery (0.15 vs. 0.12 and 0.48 vs. 0.30, respectively; p > 0.05 for both). Conclusions: We decreased opioid use after surgery by 46% without compromising pain control. In the nationwide effort to combat the opioid epidemic, health care providers can play a pivotal role as gatekeepers by decreasing reliance on opioids in the post-operative period.

had a significantly higher BMI (33 v 28 kg/m2, p[0.0001) than those within target range. On univariate analysis, higher BMI led to an increased risk of subprophylactic anti-Xa level (OR 1.2, 95% CI 1.1-1.4, p[0.0001). There were no differences in anti-Xa levels based on age, race, VTE history, operative time, or creatinine clearance.CONCLUSIONS: Higher BMI was associated with subprophylactic enoxaparin dosing after RC in a weight-based and renally dosed cohort of patients. Nearly one quarter of our cohort had below target anti-Xa levels despite standard dosing. This suggests that dosing could be further individualized, providing an even wider window of efficacy. Further studies are needed to determine the implications of dose-adjusted prophylaxis on VTE prevention.

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