Too Much or Too Little Opioid Pain Relief May Drive Refills After Urologic Surgery

WASHINGTON — Too much or too little opioid pain management at discharge after urologic surgery significantly increased the likelihood of refills, providing new insight into opioid overuse, according to a study reported here.

More than 60% of patients received discharge opioid prescriptions that were mismatched with their last in-hospital opioid dose, with underdosing accounting for a third of the mismatches. As compared with patients who received matched opioid doses at discharge, overprescription increased the odds for additional refills by as much as 85% and underprescription increased the odds by as much as 47%.

The frequency of overprescription decreased during the 8-year study period, whereas underprescription accounted for an increasingly larger share of mismatched prescriptions, reported Walter Hsiang, MD, of the University of California San Francisco (UCSF), at the American Urological Association annual meeting.

“We saw that both overprescription and underprescription independently contributed to opioid refills at 90 days,” said Hsiang. “I think it’s very important to emphasize, both within our study, but also in numerous studies in other surgical specialties, that total opioid dose reduction alone has not really been shown to decrease opioid refills. The takeaway is that we should be focusing on a patient-centered opioid-prescribing approach.”

“At our institution, we’re trying to implement a clinical-decision support tool that looks at the patient’s last 24 hours of opioid use and then come up with how much opioid to discharge patients with. Our orthopedic colleagues have published some great tapering protocols over 6 weeks,” Hsiang stated.

The study was published recently in Urology Practice.

During a discussion, an unidentified member of the audience asked whether “refills” might be the wrong metric. “If you look at the underprescribed group, maybe some of those you’re targeting might get a lower dose than what you think they might need, but they might avoid opioid issues later. That might be more beneficial, but you’ll have a small percentage that come back for refills. Is that such a bad problem?”

Hsiang responded, “It’s hard to look at long-term opioid usage. [Refill rate] is one of the closest proxies we have, but it’s a little flawed.”

Stephen Jackman, MD, of the University of Pittsburgh Medical Center, said the study “almost points out to me that you want to try to minimize opioid use in the hospital with regional anesthesia, etc. Then [patients] are not going to have to leave with any opioids. That kind of nips the problem in the bud.”

By way of background, Hsiang pointed out that a postoperative patients account for about a third of opioid prescriptions. In response to the opioid crisis over the past decade, clinical guidelines and professional societies have advocated for decreasing total opioid dosage. In urology, for example, opioid dispensing decreased by about 30% from 2016-2023. However, reducing total opioid dose has not reduced long-term refills.

“With the emphasis on drastically reducing opioid prescriptions after surgery, has the pendulum swung in the opposite direction?” said Hsiang. “Have we gone too far in the opposite direction? Are we underprescribing opioids and is it an issue?”

To examine the issue, investigators retrospectively reviewed records for 7,381 adults who had inpatient urologic surgery at UCSF from 2017 through 2024. All of the patients were hospitalized for at least 24 hours. Opioid dosing was standardized to oral morphine equivalents (OMEs). The primary objective was to examine the relationship between opioid mismatch and opioid refills in the first 90 days after hospital discharge.

Mismatch was defined as prescribed daily dose within 7.5 oral morphine equivalents (OME). Overprescription was ≥7.5 OME more than the last inpatient dose and underprescription as ≤7.5 OME below the last predischarge dose.

The results showed that 39% of patients matched opioid prescriptions at discharge, 39% had overprescribed opioids, and 22% had underprescribed opioids. In 2017, about 70% of urologic surgery patients were overprescribed at discharge, whereas about 17-18% were underprescribed. By 2024, overprescription and underprescription occurred with similar frequency (20-25%).

Investigators compared discharge opioid prescription status with refills during the first 90 days after discharge, using patients with matched prescriptions as the reference. Both overprescription and underprescription were associated with increased refill rates at 30, 60, and 90 days.

• Overprescription: OR 1.85 (95% CI 1.53-2.24), OR 1.49 (95% CI 1.15-1.93), OR 1.85 (95% CI 1.41-2.45), respectively
• Underprescription: OR 1.33 (95% CI 1.05-1.67), OR 1.22 (95% CI 0.90-1.65), OR 1.47 (95% CI 1.07-2.04)

“Increasing rates of opioid underprescription may be overlooked in clinical practice,” said Hsiang. “Total opioid dose alone is not associated with increased opioid refills. Individualizing opioid dosing based on inpatient consumption may reduce opioid mismatch after inpatient surgery.”

Investigators plan to repeat the study with a cohort of outpatients, he added.