SAN DIEGO — While urology and other medical specialties have taken steps to rein in opioid overprescribing, the skyrocketing death rate in the U.S. due to opioid overdose indicates urologists — and other healthcare providers — are not being aggressive enough in implementing safe prescribing practices, according to Benjamin Davies, MD, of the University of Pittsburgh School of Medicine.
“It is almost shocking to say that in 2022, 100,o00 people have died over the past year from opioid use,” said Davies during a session at the Society of Urologic Oncology annual meeting. “We are on a slope we have never seen before, and it doesn’t seem to be stopping.”
Davies, who is also chief of urology at the University of Pittsburgh Medical Center Shadyside/Hillman Cancer Center and director of the Urologic Oncology Program, noted that opioid prescribing patterns in the U.S., as well as in Canada, have clearly contributed to the problem. He pointed to a recent study comparing international postoperative opioid prescribing patterns showing that 91% of U.S. patients were prescribed opioids postoperatively compared with just 5% of non-U.S. patients.
“And you shouldn’t be surprised that where the drugs are given, that’s where the deaths are,” Davies observed.
As for current practice in urology, it’s “poor,” Davies said. “I’ve written about it many times. We gave out something like 200% more than we needed to give before we changed our practice.”
He referred to a recent Canadian study showing that patients were getting opioids “for the most bizarre things,” Davies said, such as minor urological procedures like vasectomy and circumcision. That study showed that 1.6% of opioid-naive patients who were prescribed postoperative opioids — in most cases after vasectomy — ended up with long-term opioid use.
“That is pretty remarkable to go in for a vasectomy, and then to have an opioid use disorder,” Davies said.
Davies urged urologists to read the American Urological Association white paper on reducing urologic postoperative opioid prescribing. “I’m not going to go through [the points] in detail, only to say that if you are a minimally invasive surgeon … you should really give patients no pills on their way home.”
When asked by session moderator Tracey Krupski, MD, of the University of Virginia in Charlottesville, when is it appropriate to prescribe opioids, Davies said there are good options in certain situations, such as for cancer pain. “For large surgeries I still give opioids in very little amounts,” he said. “I generally do not have patients go home with opioids … we generally overuse it.”
Furthermore, these patterns of overuse are not unique to urology, Davies added. “Every specialty and surgery has persistent opioid use associated with it.”
As for why the problem has exploded over the past several years. Davies keyed on two root causes: “deaths of despair” (i.e., due to suicide, alcohol, or opioids or other drug use); and the abusive marketing and targeting of opioids, such as oxycodone (OxyContin).
The Portuguese Example
In 2001, Portugal decriminalized the public and private use, and acquisition and possession, of all drugs, and adopted an approach that focused on public health, rather than public order.
As described by Davies, the most innovative aspect of the Portuguese drug policy model was the establishment of the Commissions for the Dissuasion of Drug Addiction. These multidisciplinary panels, which include doctors, lawyers, and social workers, focus on changing behaviors instead of punishing them, and getting chronic drug users to enter treatment.
“They didn’t simply make drugs legal — they decriminalized them, and make people seek treatment and have the treatment available,” Davies said. The result was a massive reduction in across-the-board problems, with deaths down to only 30 in 2016, and 11 by 2020, he said.
“If we had Portugal’s rate of opioid deaths here in 2020, only 350 Americans would have died,” Davies noted.
So what are the conclusions from the Portuguese case? “Decriminalization doesn’t increase drug use, and results in large decreases in mortality and viral transmission,” he said.
While the U.S. is highly unlikely to adopt a Portugal-like drug policy, he said, “we should have better availability of medications for opioid use disorder, and we should have high-quality treatment centers — which we don’t — and we should have databases for drug use so we can track it to make sure people are getting treatment.”
Unfortunately, he added, there are barriers to treatment. For example, patients who want to be treated with methadone have to go to dedicated centers for treatment, while naloxone is simply unavailable in some states.
“And of course, stigma, stigma, stigma is a barrier to treatment,” said Davies.
Davies had no disclosures.