Variation in opioid analgesia administration and discharge prescribing for emergency department patients with suspected urolithiasis

Renal Colic Pain Management by Tamsulosin with Morphine Versus Morphine in Adults: A Randomized Clinical Trial

Background

Acute renal colic is one of the most painful situations in patients' life. The best management modality for pain alleviation is of paramount importance.

Objectives

This study aimed to evaluate the effect of intravenously administered morphine and oral tamsulosin compared to the independent use of morphine in patients with renal colic.

Methods

This double-blind clinical trial was conducted on 200 patients aged 18 to 55 years with renal colic referred to the tertiary level referral hospital. The patients were randomly assigned to two groups, A and B. The subjects in group A were treated with intravenously administered morphine and oral tamsulosin hydrochloride capsules, while group B received morphine and control. The patients' pain intensity was evaluated using a visual analog scale.

Results

The mean age of the patients was 35.34 ± 8.32, and 72% were males. Before the study, the mean pain intensity was higher in the tamsulosin group (8.67 ± 1.53) than in the control group (7.85 ± 2.05; P = 0.003). After four and six hours, the mean pain intensity was significantly lower in the tamsulosin group (P = 0.028 and P = 0.008, respectively). According to the results, the pain intensity was significantly reduced six hours after the treatment compared to the pre-therapy phase (P < 0.001).

Conclusions

Given the significant effect of tamsulosin on pain alleviation in patients with renal colic, this medicine can be used as a complementary treatment to manage the pain in these patients and reduce the administration of narcotics.

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis

PURPOSE

Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis.

METHODS

The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods.

RESULTS

Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, - 4.3% for urolithiasis (p = 0.254) and - 5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (- 47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis.

CONCLUSIONS

The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

Opioid Analgesic Use After an Acute Pain Visit: Evidence from a Urolithiasis Patient Cohort

Introduction: Urolithiasis causes severe acute pain and is commonly treated with opioid analgesics in the emergency department (ED). We examined opioid analgesic use after episodes of acute pain. Methods: Using data from a longitudinal trial of ED patients with urolithiasis, we constructed multivariable models to estimate the adjusted probability of opioid analgesic use 3, 7, 30, and 90 days after ED discharge. We used multiple imputation to account for missing data and weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. We used weighted multivariable regression to compare longitudinal opioid analgesic use for those prescribed vs not prescribed an opioid analgesic at discharge, stratified by reported pain at ED discharge. Results: Among 892 adult ED patients with urolithiasis, 79% were prescribed an opioid analgesic at ED discharge. Regardless of reporting pain at ED discharge, those who were prescribed an opioid analgesic were significantly more likely to report using it one, three, and seven days after the visit in weighted multivariable analysis. Among those who were not prescribed an opioid analgesic, an estimated 21% (not reporting pain at ED discharge) and 30% (reporting pain at discharge) reported opioid analgesic use at day three. Among those prescribed an opioid analgesic, 49% (no pain at discharge) and 52% (with pain at discharge) reported using an opioid analgesic at day three. Conclusion: Urolithiasis patients who received an opioid analgesic at ED discharge were more likely to continue using an opioid analgesic than those who did not receive a prescription at the initial visit, despite the time-limited nature of urolithiasis.

Disparities in Prehospital Non-Traumatic Pain Management

INTRODUCTION

While prior research has identified racial disparities in prehospital analgesia for traumatic pain, little is known about non-traumatic pain. Using a national prehospital dataset, we sought to evaluate for racial and ethnic disparities in analgesia given by EMS for non-traumatic pain.

METHODS

We analyzed the 2018 and 2019 data from the ESO Data Collaborative, a collection of de-identified prehospital electronic health records from nearly 1,300 participating EMS agencies in the US. We included all transported, adult, non-traumatic encounters with a primary or secondary impression of a pain complaint, and we stratified encounters based on race and ethnicity as recorded by the EMS clinicians. We performed a mixed model analysis, modeling EMS agency as a random intercept and adjusting for age, sex, pain location, level of service, location of incident, and highest pain score. With non-Hispanic White patients as the reference group, we then evaluated the association between race/ethnicity and receiving any pain medication (acetaminophen, non-steroidal anti-inflammatories, or opioids), receiving opioid pain medication, and receiving pain medication within 20 minutes of EMS arrival.

RESULTS

We included 1,035,486 patients; 67.5% non-Hispanic White, 26.8% Black, 4.9% Hispanic, 0.5% Asian, 0.1% Native Hawaiian or Other Pacific Islander, and 0.2% American Indian or Alaska Native patients. 4.7% of patients received pain medications. Compared to White patients (5.1%), Black patients were less likely to receive pain medication (3.3%, aOR 0.7; 95% CI 0.7-0.7) and Hispanics were more likely to receive pain medication (7.6%, aOR 1.5; 95% CI 1.4-1.6). Black patients were also less likely to receive opioids (1.8% for Black v 3.0% for White, aOR 0.7; 95% CI 0.6-0.7), while Hispanic patients were more likely to receive opioids (4.9%, aOR 1.4; 95% CI 1.3-1.5). The odds of receiving pain medication within 20 minutes was lower for Black patients (aOR 0.9; 95% CI 0.8-0.95) but no different for Hispanic patients (aOR 1.0; 95% CI 0.9-1.1), when compared to White patients.

CONCLUSION

Pain medication administration is uncommon for non-traumatic pain complaints. While Black patients were less likely than White patients to receive pain medications and receive pain medication within 20 minutes, Hispanics were more likely to receive pain medications.

National trends and prescription patterns in opiate analgesia for urolithiasis presenting to Emergency Departments: Analysis of the National Hospital Ambulatory Medical Care Survey, 2006-2018

OBJECTIVE

To analyze the National Hospital Ambulatory Medical Care Survey (NHAMCS) database to determine geographic and temporal trends, as well as variables associated with the likelihood of receiving an opioid prescription for urolithiasis in US EDs.

METHODS

All ED visits for urolithiasis between 2006-2018 in the NHAMCS database were analyzed. Age, race/ethnicity, insurance status, ED provider credentials, geographic region, and urban vs. rural hospital status were extracted. Linear regression was used to examine overall/regional trends in opioid prescriptions over time. Logistic regression was used to estimate factors associated with higher odds of receiving opioids.

RESULTS

Fourteen million visits were analyzed, of which, 79.1% (11.0 million) received an opioid prescription. From 2014-2018 there was a decline of 3.65%/year of the proportion of visits receiving an opioid prescription (R²=0.86, p=0.008). Non-Hispanic Black race was associated with a lower chance of receiving opioid prescription (OR=0.57, p=0.02) compared to Non-Hispanic Whites (NHW). Midwestern hospitals had higher odds of opioid prescription compared to the Northeast (OR=2.05, p=0.006). Rural hospitals had lower odds of opioid prescription compared to urban hospitals (OR=0.62, p=0.02).

CONCLUSION

Opioid prescriptions for patients presenting with urolithiasis to the ED have steadily declined from 2014-2018, except in the Midwest. NHW race, Midwest region, and urban EDs increase the likelihood of receiving opioids. Continued efforts encouraging non-opioid alternatives for urolithiasis are essential, specifically in Midwestern EDs, to mitigate the ongoing opioid epidemic in the US.

Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients

BACKGROUND

Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain.

OBJECTIVES

Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis.

METHODS

We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge.

RESULTS

Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90.

CONCLUSIONS

Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.

Disparities in Kidney Stone Disease: A Scoping Review

PURPOSE

We reviewed the available evidence regarding health disparities in kidney stone disease to identify knowledge gaps in this area.

MATERIALS AND METHODS

A literature search was conducted using PubMed®, Embase® and Scopus® limited to articles published in English from 1971 to 2020. Articles were selected based on their relevance to disparities in kidney stone disease among adults in the United States.

RESULTS

Several large epidemiological studies suggest disproportionate increases in incidence and prevalence of kidney stone disease among women as well as Black and Hispanic individuals in the United States, whereas other studies of comparable size do not report racial and ethnic demographics. Numerous articles describe disparities in imaging utilization, metabolic workup completion, analgesia, surgical intervention, stone burden at presentation, surgical complications, followup, and quality of life based on race, ethnicity, socioeconomic status and place of residence. Differences in urinary parameters based on race, ethnicity and socioeconomic status may be explained by both dietary and physiological factors. All articles assessed had substantial risk of selection bias and confounding.

CONCLUSIONS

Health disparities are present in many aspects of kidney stone disease. Further research should focus not only on characterization of these disparities but also on interventions to reduce or eliminate them.