Introduction

The opioid epidemic has reached alarming proportions, with sale of prescription opioids and overdose-related deaths quadrupling since 1999.¹ Given increased accessibility of addictive opioids, the American Urological Association (AUA) strongly believes urologists have a responsibility to minimize their patients' pain and also address serious risks of overprescribing opioids.  

Opioid Duration and Amount

Urologists should manage their patients' pain in a way that addresses the needs of the individual patient while also considering the impact of opioid use on the larger population and society. When opioids are necessary, the lowest dose and lowest potency to adequately control pain from surgery and other conditions and discontinued as soon as possible. Non-narcotic methods of managing pain, including anti-inflammatories, acetaminophen, and non-medication approaches, should be used when appropriate and adequate. Policies limiting or interfering with the ability of urologists to adequately manage their patients' pain should be avoided. Educating patients prior to surgery about pain management expectations, protocols, and options is an important part of adequately caring for patients while also responsibly prescribing opioids. The U.S. Food & Drug Administration (FDA) recommends all providers counsel patients and/or their caregivers about the safe use of opioids, serious risks, proper storage and disposal with every prescription. Urologists can download (or order) and use the new Opioid Analgesic Patient Counseling Guide (available in English or Spanish) in outpatient setting as an Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS).   

Prescription Drug Monitoring Programs

Other principles to facilitate the appropriate use of opioids include the use of Prescription Drug Monitoring Programs (PDMPs). PDMPs correlate with improved outcomes and decreased opioid-related deaths. Urologists should utilize PDMPs whenever available or required. While the AUA promotes the use of PDMPs, some PDMPs may require improvements in efficiency, particularly when functionality limits access to care. Additional improvements to the consistency and alignment of states' PDMPs are essential, allowing for improved interstate collaboration. Another key component is the ability for urologists to use their Electronic Health Records (EHRs) to e-prescribe narcotics. It is imperative that EHR systems, as well as state and federal regulations, make e-prescription as easy as possible. E-prescribing controlled medications has improved the ability to monitor use as well as has decreased the possibility of fraud. Programs and legislation to enhance the interactive functions of PDMPs, EHRs, and e-prescription of controlled substances are necessary to simplify the use of these tools by urologists. Any requirements to enhance the interactive functions should be directed to EHR vendors, and avoid placing additional burdens on physicians.  

Opioid Use in the Setting of Chronic Opioid Use or Substance Abuse Disorders

In 2016, the AUA endorsed standardized guidelines from the Centers for Disease Control and Prevention (CDC) for use of prescription narcotics in the management of chronic pain.² Urologists should be aware of these guidelines given that they may treat patients with chronic pain, either for primary management of conditions such as chronic pelvic pain syndrome or acute management of post-surgical pain among patients with chronic pain syndromes. Furthermore, given patients on chronic opioids are at higher risk of overdose,³ urologic providers should be educated about the reversal agent naloxone and its proper distribution. Special considerations should be made for those patients experiencing acute on chronic pain, particularly after surgery. Postoperative pain control in chronic pain patients on opioids may require increased amounts of opioids to provide adequate relief due to tolerance.^4,5 Opioid-tolerant patients may experience more pain postoperatively, especially in the first 24 to 48 hours. Therefore, preoperative planning should involve input from the patient's caregivers and rely on multimodal agents such as non-steroidal anti-inflammatory medications and acetaminophen. Patients with underlying substance use disorders ⁶ can also present a challenge due to risks for  alcohol, opioid and nicotine withdrawal and related complications, hypersensitivity to pain, ineffective coping mechanisms, psychosocial issues, fear of mistreatment and unrealistic expectations. In these patient populations, a multimodal pain management approach should involve shared decision making, expectation setting. Involvement of family/caregivers along with pain and addiction treatment specialists to assist the urologist can help to design a safe and comprehensive treatment plan. Preoperative consultation with a pain specialist may be particularly beneficial, to assist with risk stratification and management recommendations.  

Risks of Opioid Use

The greatest concerns with opioid use are the serious risks of dependence, long-term use, overdose, misuse and addiction with any exposure to the medication class. Urologists have a responsibility to educate their patients regarding the serious risks of opioid use, and consult a pain service or pharmacy if needed. Risks can be described by their frequency and severity. Constipation is a frequent side effect. Respiratory depression is a life threatening side effect associated with opioid use and higher doses and may occur during sleep, particularly among patients with sleep apnea, other breathing disorders. Importantly, patients should be counseled that severe side effects (including unintentional overdose) may result from mixing opioid use with other sedatives such as alcohol or prescription anti-anxiety and anti-insomnia medications. Less well known side effects include hyperalgesia (increase in pain), musculoskeletal injuries with falls and fractures, especially to the hip and pelvis, and severe intestinal obstruction from extreme constipation. Hormonal effects commonly occur in male patients with chronic opioid use and can cause low testosterone levels (hypogonadism), impotence, infertility, and osteoporosis. Dry mouth and tooth decay have also been reported with prolonged use. Overall, chronic use and dose effects associated with risks can be severe. 

Storage and Disposal of Opioids⁷

Surplus opioid medications in the home or community increase the likelihood of diversion and misuse. Urologists should be aware of these risks and can mitigate them when they appropriately educate all patients to whom they prescribe opioid medications. Safe storage of opioids in their original bottle and in a locked container should be recommended especially in households where children could inadvertently access these medications. Along with thoughtfully prescribing opioids to limit surpluses in the community, urologists should advise patients to properly dispose of excess medications. Options for safe disposal of opioids may vary by community and medication. Urologists should familiarize themselves with local options and share these with recipients of opioid prescriptions. Common options for disposal include pharmacy drop-off, drug enforcement agency or police sponsored take-back events or drop off locations, and healthcare center based drop-off locations. Specifically for opioid medications, the U.S. Food & Drug Administration (FDA) recommends against throwing them in the trash, even if mixed with other unpalatable substances (e.g., coffee grounds, cat litter). When takeback options are not available, the FDA recommends these medications be flushed down the toilet for safe disposal given the higher risk of accidental exposure for opioid medications. Commercially available destruction kits are an option for disposal as well. 

Non-Legitimate Access to Opioids

As responsible stewards of patients' appropriate utilization of opioids, urologists must not only strive for best practices as prescribing physicians, but must take a strong stand for the enforcement of rules and regulations that prevent manufacturers, distributers, and retailers from inappropriately supplying opioids to the communities urologists serve. Rules have been put in place by the Drug Enforcement Agency (DEA) requiring distributers to report orders that appear incongruent with normal prescribing patterns, but these rules have not been followed over the years despite fines and reprimands. Large-scale distributers of opioids have been cited by the DEA for insufficiently monitoring the distribution of opioids to fraudulent retailers, resulting in distributions of hundreds of doses of opioids for every man, woman, and child in some communities. To date, more than 300 lawsuits have been brought against major distributers by various state attorney generals, other municipalities, and the Cherokee Nation.  Although a great deal of attention has been appropriately placed on the role of the prescribing doctor, attention must also be focused on this introduction of narcotics into our communities, which is completely out of the control of the legitimate prescribing urologist.

Urologists have a responsibility to be stewards of safe opioid use. Through careful opioid prescribing, patient education, and awareness of risk, urologists can provide quality care for patients and positively impact a critical public health epidemic.

1. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html

2. American Urological Association. http://www.auanet.org/guidelines/opioid-prescriptions-for-chronic-pain

3. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Overdose and prescribed opioids: Associations among chronic non-cancer pain patients. Ann Intern Med 2010; 152(2): 85-92.

4. Patanwala AE, Jarzyna DL, Miller MD, Erstad BL. Comparison of opioid requirements and analgesic response in opioid-tolerant versus opioid-naive patients after total knee arthroplasty. Pharmacotherapy 2008; 28(12):1453-1460.

5. Kosten TR, George TP. The neurobiology of opioid dependence: Implications for treatment. Sci Pract Perspect. 2002;1(1):13-20.

6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Publishing 2013;541-560.

7. US Food and Drug Administration.  https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm#Medicines_recommended

_{Board of Directors, August 2018
Board of Directors, January 2019 (Revised)}