Opiate Exposure and Predictors of Increased Opiate Use After Ureteroscopy

Nonopioid Pain Management Pathways for Stone Disease

Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.

Optimizing pain management following kidney stone surgery: can we avoid narcotics?

INTRODUCTION

Opioids are often used to manage postoperative pain. Non-narcotic alternatives have increasingly been used to reduce opioid usage. We conducted an open-label randomized non-inferiority clinical trial to compare non-opioid to opioid therapy for pain management after nephrolithiasis surgery.

METHODS

Patients undergoing elective ureteroscopy or percutaneous nephrolithotomy between July 2018 and May 2021 were randomized to receive ketorolac (non-opioid) or oxycodone-acetaminophen (opioid). Each patient was surveyed one week postoperatively to assess pain outcomes. Patient demographics, surgical variables, number of pills used, constipation, and adverse events were also assessed. We evaluated whether non-opioid analgesia was non-inferior to opioid analgesia for postoperative pain, assuming a non-inferiority margin of 1.3 in pain score between groups.

RESULTS

Analyses were based on 90 patients with postoperative pain data: 44 in the ketorolac group and 46 in the oxycodone-acetaminophen group. The groups were similar regarding demographics, type of surgery, ureteral stent placement, and stone burden. Non-inferiority of non-opioids compared to opioids was demonstrated for all outcomes. At follow-up, the average pain scores were 3.20 ± 1.94 (SD) in the non-opioid group and 4.17 ± 1.84 in the opioid group (difference =  - 0.96; 95% CI: - 1.76, - 0.17, p = 0.018). The mean proportions of unused pills were similar between groups (p = 0.47) as were rates of constipation (p = 0.32).

CONCLUSIONS

Non-opioid analgesia was non-inferior to opioid analgesia in pain management after kidney stone surgery. This trial contributes to the evidence that non-opioid analgesics should be considered an effective option for pain management following non-invasive urologic procedures.

Optimizing pain management following kidney stone surgery: can we avoid narcotics?

INTRODUCTION

Opioids are often used to manage postoperative pain. Non-narcotic alternatives have increasingly been used to reduce opioid usage. We conducted an open-label randomized non-inferiority clinical trial to compare non-opioid to opioid therapy for pain management after nephrolithiasis surgery.

METHODS

Patients undergoing elective ureteroscopy or percutaneous nephrolithotomy between July 2018 and May 2021 were randomized to receive ketorolac (non-opioid) or oxycodone-acetaminophen (opioid). Each patient was surveyed one week postoperatively to assess pain outcomes. Patient demographics, surgical variables, number of pills used, constipation, and adverse events were also assessed. We evaluated whether non-opioid analgesia was non-inferior to opioid analgesia for postoperative pain, assuming a non-inferiority margin of 1.3 in pain score between groups.

RESULTS

Analyses were based on 90 patients with postoperative pain data: 44 in the ketorolac group and 46 in the oxycodone-acetaminophen group. The groups were similar regarding demographics, type of surgery, ureteral stent placement, and stone burden. Non-inferiority of non-opioids compared to opioids was demonstrated for all outcomes. At follow-up, the average pain scores were 3.20 ± 1.94 (SD) in the non-opioid group and 4.17 ± 1.84 in the opioid group (difference =  - 0.96; 95% CI: - 1.76, - 0.17, p = 0.018). The mean proportions of unused pills were similar between groups (p = 0.47) as were rates of constipation (p = 0.32).

CONCLUSIONS

Non-opioid analgesia was non-inferior to opioid analgesia in pain management after kidney stone surgery. This trial contributes to the evidence that non-opioid analgesics should be considered an effective option for pain management following non-invasive urologic procedures.

Tubeless Ureterorenoscopy-Our Experience Using a 120 W Laser and Dusting Technique: Postoperative Pain, Complications, and Readmissions

Introduction and Objective: Both double J-stent (DJS) and ureter catheter (UC) drainage represent routine practice following ureterorenoscopy. In select situations, a tubeless approach is possible and safe. In tubeless cases, we use a sheathless dusting technique with the Lumenis® MOSES Pulse™120 H Holmium: YAG laser. We evaluated these three drainage subgroups and compared postoperative pain, complications, and readmissions. Methods: A retrospective database of 269 consecutive patients who underwent primary ureterorenoscopy for the treatment of upper urinary tract stones between October 2018 and August 2019. The cohort was divided according to post-operative drainage as Tubeless, UC, and DJS. The decision on whether to perform post-operative drainage was by surgeon preference. Demographic and clinical parameters such as stone location, number, and burden, hydronephrosis grade, and postoperative complications (fever, acute renal failure, and the obstruction of the upper urinary tract by Stone Street) were assessed. Pain was assessed using a 0−10 Visual Analog Scale score (VAS) and the use of analgesics by dose/case in each group. Results: There were 70 (26%) tubeless, 136 (50%) UC, and 63 (24%) DJS cases. Patients drained with DJSs had a significantly higher stone burden, more severe obstruction, and prolonged operative time. Tubeless and UC-drained patients had the same stone characteristics with maximal diameters of 8.4 (6.1−12) mm and 8 (5.2−11.5) mm in comparison to the stented group, with 12 (8.6−16.6) mm, p < 0.01. The operation time was the longest in the stented group at 49 min (IQR 33−60) in comparison to the UC and tubeless groups at 32 min (23−45) and 28 min (20−40), respectively (p < 0.001). Auxiliary procedures were more prevalent in the stented group, but the overall stone-free rate was not significantly different, p = 0.285. Postoperative ER visits, readmissions, and complications were the highest in the UC-drained group, at 20% in the UC vs. 6% in the tubeless and 10% in the stented groups. Post-operative pain levels and analgesic use were significantly lower in the tubeless group with a significant reduction in opiate usage. Conclusions: A tubeless approach is safe in selected cases with fewer post-operative complications. While DJS should be considered in complex cases, UC may be omitted in straightforward cases since it does not appear to reduce immediate postoperative complications. Those fitted for tubeless procedures had improved postoperative outcomes, facilitating outpatient approach to upper urinary tract stone treatment and patient satisfaction.

Opioids in Urology: How Well Are We Preventing Opioid Dependence and How Can We Do Better?

Urologic procedures (both open and minimally invasive) can cause pain due to the surgery itself, devices placed, and post-operative issues. Thus, pain management is important for every post-procedure recovery period. Opioid use post-surgery is common and often over-prescribed contributing to persistent use by patients. In this article, we review the extent of opioid use in pediatric urologic procedures, vasectomy, endourologic procedures, penile implantation, urogynecologic procedures, prostatectomy, nephrectomy, cystectomy, and scrotal/testicular cancer surgery. Generally, we have found that institutions do not have a standardized protocol with a set regimen to prescribe opioids, resulting in more opioids being prescribed than needed and patients not properly disposing of their unused prescriptions. However, many institutions recognize their opioid overuse and are implementing new multimodal opioid-sparing analgesics methods such as non-opioid peri-operative medications, minimally invasive robotic surgery, and nerve blocks or local anesthetics with varying degrees of success. By shedding light on these opioid-free methods and prescription protocols, along with improved patient education and counselling, we hope to bring awareness to institutions and decrease unnecessary opioid use.

A prospective randomized study evaluating the necessity of narcotics following ureteroscopy for urinary stone disease

PURPOSE

To evaluate the efficacy of non-narcotic analgesics and preoperative counseling in managing postoperative pain and narcotic use following ureteroscopic laser lithotripsy (URS).

METHODS

Adult patients at a single academic center undergoing URS for nephrourolithiasis were recruited. After informed consent, subjects were randomized into three groups: NARC-15 tablets oxycodone-acetaminophen 5/325 mg (A-OXY), 2. NSAID-15 tablets ibuprofen (IBU) 600 mg, 3. CNSL-15 tablets A-OXY, 15 tablets IBU, and preoperative counseling from the surgeon to avoid narcotic if possible. Patients who did not receive an intraoperative stent were excluded. At the time of stent removal subjects completed the Universal Stent Symptom Questionnaire (USSQ), and a pill count was performed. USSQ pain indices were the primary study endpoint.

RESULTS

Of 115 patients enrolled, 104 met the primary endpoint and were included in the analysis. No significant differences were noted in patient demographic, clinical, or operative characteristics. No differences were noted in median USSQ pain indices. The CNSL group used a significantly lower median number of A-OXY pills compared to the NARC group (2.4 vs. 5.4, p = 0.001) and less IBU compared to the NSAID group (3.1 vs. 5.9, p = 0.008). No differences in median total pill count, office calls, medication requests, nor ED visits were noted.

CONCLUSION

Our data suggest that patients can achieve equivalent postoperative analgesic satisfaction with non-narcotics compared to opiates following URS. Further, counseling patients on postoperative pain before surgery can reduce the total number of postoperative narcotic and non-narcotic medications taken. We suggest surgeons strongly consider omission of narcotic prescriptions following non-complicated URS.

Barriers in Managing Acute Ureteric Colic Clinical Review and Commentary

With the global prevalence of urolithiasis increasing, the presentation of acute ureteric colic to emergency departments (ED) poses a significant burden on healthcare systems globally. Management strategies for ureteric colic encompass medical expulsion therapy and various interventional modalities aimed at urinary diversion or definitive stone management. By examining potential or established barriers to managing acute ureteric colic, we can minimise strain on healthcare providers while maintaining patient outcomes. This review aims to assess barriers to the management of acute ureteric colic through a comprehensive overview of the current literature. Acute ureteric colic barriers will be assessed throughout a patient’s disease progression, borrowing a conceptual framework used to assess barriers in cancer care management. Barriers will be discussed in the context of patient-centred access to healthcare, clinical evaluation and diagnosis, and management. Numerous barriers to healthcare have been identified throughout the natural course of acute ureteric colic, both specific and non-specific. Patient-centred barriers typically arise during the initial onset of acute ureteric colic. Originating from patient awareness and access to healthcare, they include barriers founded on race inequalities, cultural beliefs, geographic location, transportation, and the concept of a universal standard of healthcare. Having accessed healthcare, barriers in the management of acute ureteric colic next occur during the clinical evaluation and diagnosis period. These are typically associated with clinical assessment or diagnostic imaging delays, including underutilisation of ultrasound, nurse-led pathways for faster clinical reviews, and general ED delays. The final period during acute ureteric colic management correlates to clinical management. The inherent unpredictable course of ureteral stones leads to poor prognostication and failed initial management modalities. Additionally, this period deals with periprocedural delays and preventative health. Barriers to the management of acute ureteric colic arise during a patient's journey through accessing healthcare. Reviewing barriers allow further research into areas requiring modification to expedite care and improve outcomes.

Opioid-Free Discharge is Not Associated With Increased Unplanned Healthcare Encounters After Ureteroscopy: Results From a Statewide Quality Improvement Collaborative

OBJECTIVES

To evaluate patient factors associated with post-ureteroscopy opioid prescriptions, provider-level variation in opioid prescribing, and the relationship between opioid-free discharges and ED visits.

METHODS

This is a retrospective analysis of a prospective cohort study of adults age 18 years and older who underwent primary ureteroscopy for urinary stones from June 2016 to September 2019 within the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) quality improvement initiative. Postoperative opioid prescription trends and variation among practices and surgeons were examined. Multivariable logistic regression models defined risk factors for receipt of opioid prescriptions. The association among opioid prescriptions and postoperative ED visits within 30 days of surgery was assessed among complete case and propensity matched cohorts, matched on all measured characteristics other than opioid receipt.

RESULTS

13,143 patients underwent ureteroscopy with 157 urologists across 28 practices. Post-ureteroscopy opioid prescriptions and ED visits declined (86% to 39%, P<.001; 10% to 6%, P<.001, respectively). Practice and surgeon-level opioid prescribing varied from 8% to 98%, and 0% to 98%, respectively. Patient-related factors associated with opioid receipt included male, younger age, and history of chronic pain. Procedure-related factors associated with opioid receipt included pre- and post-ureteroscopy ureteral stenting and access sheath use. An opioid-free discharge was not associated with increased odds of an ED visit (OR 0.77, 95% CI 0.62-0.95, P=.014).

CONCLUSIONS

There was no increase in ED utilization among those not prescribed an opioid after ureteroscopy, suggesting their routine use may not be necessary in this setting.

Opioid-sparing analgesic effects of peripheral nerve blocks in percutaneous nephrolithotomy: a systematic review

INTRODUCTION

Multimodal analgesia regimens incorporating peripheral nerve blocks (PNB) have demonstrated reduced postoperative pain, opioid use, and recovery time in various disease states. However, this remains a subject of limited investigation in the percutaneous nephrolithotomy (PCNL) domain. In the face of an ongoing opioid epidemic and collective push to enhance prescribing stewardship, we sought to examine the potential opioid-sparing effect of PNB in PCNL.

METHODS

A systematic review of Embase and PubMed was performed to identify all randomized controlled trials evaluating the use of a PNB with general anesthesia (GA) versus GA alone for pain control following PCNL. Studies evaluating neuraxial (epidural and spinal) anesthesia and those without GA as the control arm were excluded.

RESULTS

Seventeen trials evaluating 1012 procedures were included. Five different blocks were identified and evaluated: paravertebral (n=8), intercostal nerve (n=3), quadratus lumborum (n=2), transversus abdominis plane (n=1), and erector spinae (n=3). 9/16 (56%) studies observed lower pain scores with PNB use throughout the 24-hour postop period. By comparison, improved pain scores with PNB were limited to the early (<6 hours) recovery period in 5 studies and 2 found no difference. Total analgesia and opioid requirements were significantly higher in the GA control arm in nearly all studies (12/14, 86%). Operative times were similar and there were no differences in rates of intercostal access or nephrostomy tube insertion between study arms in any trial.

CONCLUSION

While greater analgesic use with GA alone likely minimizes or obscures differences in patient-reported pain scores, PNB may offer a significant opioid-sparing analgesic effect during postoperative recovery after PCNL.

Evidence-Based Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery

INTRODUCTION

Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus.

METHODS

A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naïve adult patients after uncomplicated procedures.

RESULTS

Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement.

CONCLUSION

Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making prior to prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.

Opioid Free Ureteroscopy: What is the True Failure Rate?

OBJECTIVE

To determine the true failure rate of opioid free ureteroscopy (OF-URS) and rates of new-persistent opioid use utilizing a national prescription drug monitoring program.

MATERIAL AND METHODS

We identified 239 patients utilizing our retrospective stone database who underwent OF-URS from Februrary 2018-March 2020. In Feb 2018, we initiated a OF-URS pathway (diclofenac, tamsulosin, acetaminophen, pyridium and oxybutynin). Patients who had a contraindication to NSAIDs were excluded from primary analyses. A prescription drug monitoring program was then utilized to determine the number of patients who failed OF-URS (defined as receipt of an opioid within 31 days of surgery) as well as rates of new-persistent opioid use (defined as receipt of opioid 91-180 days after surgery). All statistical analyses were performed using SAS 9.4. Tests were 2-sided and statistical significance was set at P<0.05.

RESULTS

We found a OF-URS failure rate of 16.6% and 14.0% in the total and opioid naïve cohorts, respectively. Rates of new-persistent opioid use were 0.9% and 1.2%, respectively (lower than published expected rate of ~6% after URS with postoperative opioids). 91% of patients obtained opioid from alternative sources. Uni/multivariate analyses were performed for both cohorts. In the total cohort, benzodiazepine users had a lower risk of OF-URS failure on multivariate analysis. No variables were associated with OF-URS failure in the opioid naïve cohort.

CONCLUSION

The true failure rate of OF-URS is higher than previously thought at 16.6% and 14.0%. However, efforts to reduce opioid prescriptions with OF-URS pathways have successfully reduced new-persistent opioid use.

Patterns of opioid prescription post ureteroscopy among members of the Endourological Society

Background

Postoperative opioid prescribing has been linked with persistent opioid use. Ureteroscopy (URS) is a common urologic procedure and a potential area to focus on opioid reduction. We aim to characterize international practice patterns of opioid prescribing post URS and what measures may decrease the need for opioid prescription.

Methods

We developed a survey directed to members of the Endourological Society. The survey queried the frequency of opioid prescribing post URS, challenges when opioids are not prescribed, and measures thought to reduce the need for opioids.

Results

We received 159 responses with the majority reported practicing urology for >20 years (37.1%), and performing 10–20 ureteroscopies/month (45.3%). Forty-one percent were from the United States (US) and Canada. Sixty-six percent completed a fellowship, 84% in endourology. Twenty-six percent prescribe opioids more than half the time and the majority do so less than 10% of the time (61.6%). Thirty-eight percent had no challenges when opioids were omitted. Measures felt to decrease the need for opioids were preoperative counseling, nonsteroidal anti-inflammatory drugs use, and use of adjunct medications. After adjusting for location and type of practice, endourology fellowship completion, years of practice, and number of ureteroscopies/month, we found that respondents from the US and Canada were more likely to prescribe opioids more than half the time post URS compared to respondents from the rest of the world [odds ratio (OR): 87.5, P<0.001, 95% confidence interval (CI): 17.3–443.5].

Conclusions

Despite proven feasibility of non-opioid pathway, nearly one-quarter of participants in our survey prescribe opioids >50% of the time post URS. Most important factors felt to reduce opioid prescription post URS were preoperative counseling, nonsteroidal anti-inflammatory drugs use. US and Canadian urologists were more likely to prescribe opioids >50% of the time post URS compared to the rest of the world. We believe best practice guidelines should be considered by the American and Canadian Urological Associations to address post URS opioid prescribing.

Prescribing Trends in Post-operative Pain Management After Urologic Surgery: A Quality Care Investigation for Healthcare Providers

OBJECTIVE

To assess prescribing and refilling trends of narcotics in postoperative urology patients at our institution. Although the opioid epidemic remains a public health threat, no series has assessed prescribing patterns across urologic surgery disciplines following discharge.

METHODS

All urologic surgeries were retrospectively reviewed from May 2017-April 2018. Demographics, comorbidities, and postoperative pain management strategies were analyzed. Narcotics usage following surgery were reported in total morphine equivalents (TME). Opioid refill rate was characterized by medical specialty and stratified by urologic discipline.

RESULTS

817 cases were reviewed. Mean age and TME at discharge was 57±15.6 years and 35.43±19.5 mg, respectively. 13.6% (mean age 55±15.9) received a narcotic refill following discharge (mean TME/refill 37.7±28.9 mg). A higher proportion of patients with a pre-operative opioid prescription received a refill compared to opioid naïve patients (38.2% vs 21.6%, P < .01). Refill rate did not differ between urologic subspecialties (P = .3). Urologists were only responsible for 20.4% of all refills filled, despite all patients continuing follow-up with their surgeon. Procedures with the highest rates of post-operative refills were in oncology, male reconstruction/trauma and endourology. Patients with a history of chronic pain (OR 1.9, CI 1.1-3.3) preoperative narcotic prescription (OR 1.6, CI 1.0-2.6), and higher ASA score (OR 1.8, CI 1.6-2.8) were more likely to obtain a postoperative opioid prescription refill.

CONCLUSION

Approximately 1 in 7 postoperative urology patients receive a postoperative narcotics refill; however, nearly two-thirds receive refills exclusively from non-urologic providers. Attempts to avoid overprescribing of postoperative narcotics need to account for both surgeon and nonsurgeon sources of opioid refills.

Opioids and Kidney Stones

In recent years, the use of opioids in medical practice has come under significant scrutiny. This, in part, is owing to evidence of overprescription and overuse of opioid medications, as well as the unintended consequences and side effects for patients who take these medications. Here, we review the role of opioids and the responsible use of these medications with respect to kidney stone disease and surgical interventions for kidney stones.

Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage

OBJECTIVES

To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease.

METHODS

We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP.

RESULTS

We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant.

CONCLUSION

Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.

Opiates prescribed for acute renal colic are associated with prolonged use

PURPOSE

Patients presenting with acute renal colic may be at risk of opiate abuse. We sought to analyze prescribing patterns and identify risk factors associated with prolonged opiate use during episodes of acute renal colic.

METHODS

Retrospective study of patients presenting with both a stone confirmed on imaging and an acute pain episode from 6/2017-2/2020. Opiate prescription data was obtained from a statewide prescribing database. Primary outcome was an opiate refill or new opiate prescription prior to resolution of the stone episode (either passage or surgery). Univariate and multivariate linear regression analysis was performed.

RESULTS

A total of 271 patients met inclusion criteria. Mean age was 52 years and 48% had a history of nephrolithiasis. 180 (66%) patients filled a new opiate prescription during their acute stone episode. Thirty-eight (14%) patients had an existing opiate prescription within 3 months of their stone episode. Seventy-four (27%) patients refilled an opiate prescription prior to stone passage or surgery. Larger stone size, need for surgery, prolonged time to treatment, existing opiate prescription, new opiate prescription at presentation, and greater initial number of pills prescribed were associated with increased risk of requiring a refill prior to stone resolution.

CONCLUSIONS

Patients prescribed new opiates for acute nephrolithiasis and those with an existing opioid prescription are likely to require refills before resolution of the stone episode. Larger stones that require surgery (not spontaneous passage) also increase the risk. Timely treatment of these patients and initial treatment with non-narcotics may reduce the risk of prolonged opiate use.

Urolithiasis in the COVID Era: An Opportunity to Reassess Management Strategies

Delayed evaluation and/or treatment for urolithiasis during the COVID-19 pandemic provide a unique opportunity to organically reassess many well-established stone management strategies. Nonopioid analgesia for renal colic and spontaneous passage trials appear to be two avenues worthy of investigation.

Increased risk of new persistent opioid use in pediatric and young adult patients with kidney stones

INTRODUCTION

Adolescents and young adults are a vulnerable patient population for development of substance use disorder. However, the long-term impact of opioid prescribing in young adult patients with renal colic is not known. Our objective was to describe rates of opioid prescription and identify risk factors for persistent opioid use in patients age 25 years or younger with renal colic from kidney stones.

METHODS

Using previously validated, linked administrative databases, we performed a population-based, retrospective cohort study of opioid-naive patients age 25 years or younger with renal colic between July 1, 2013 and September 30, 2017 in Ontario. All family practitioner, urgent care, and specialist visits in the province were captured. Our primary outcome was persistent opioid use, defined as filling a prescription for an opioid between 91 and 180 days after initial visit. Ontario uses a narcotic monitoring system, which captures all opioids dispensed in the province.

RESULTS

Of the 6962 patients identified, 56% were prescribed an opioid at presentation and 34% of those were dispensed more than 200 oral morphine equivalents. There was persistent opioid use in 313 (8.1%) patients who filled an initial opioid prescription. In adjusted analysis, those prescribed an opioid initially had a significantly higher risk of persistent opioid use (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.50-2.29) and opioid overdose (OR 3.45; 1.08-11.04). There was a dose-dependent increase in risk of persistent opioid use with escalating initial opioid dose. History of mental illness (OR 1.32; 1.02-1.71) and need for surgery (OR 1.71; 1.24-2.34) were also associated with persistent opioid use.

CONCLUSIONS

Among patients with kidney stones age 25 years or younger, filling an opioid prescription after presentation is associated with an increased risk of persistent opioid use 3-6 months later and a higher risk of serious long-term complications, such as opioid overdose.

Enhanced Recovery After Surgery Protocol for Patients Undergoing Ureteroscopy: Prospective Evaluation of an Opioid-Free Protocol

Purpose: A large part of the national opioid epidemic has been tied to prescription opioids, leading to a push to reduce or eliminate their use when feasible. The objective of this study was to evaluate outcomes of implementing an Enhanced Recovery After Surgery (ERAS) protocol for patients undergoing ureteroscopic stone treatment with stent placement geared toward minimizing opioid use. Materials and Methods: We performed a pre-post study concerning a process improvement project of consecutive patients undergoing ureteroscopic stone treatment with stent placement utilizing a novel ERAS protocol. A lead-in period with patients managed conventionally with opioids was performed before implementation of the ERAS protocol. Data regarding opioid utilization, postoperative outcomes, and patient-reported outcomes, including Patient-Reported Outcomes Measurement Information System (PROMIS), were compared between groups. Results: There were 28 pre-ERAS patients and 52 ERAS-managed patients. Patients discharged with an opioid prescription decreased from 93% to 0% (p < 0.05). Mean total morphine milligram equivalent decreased from 60.1 ± 41 to 7.7 ± 26 (p < 0.05). There was no significant difference noted for postoperative calls for pain in the pre-ERAS vs ERAS groups (25% vs 19%, p = 0.9) or in unscheduled provider encounters (0% vs 4%, p = 0.46). There were no clinically significant differences between groups on patient-reported measures. Conclusions: Implementation of an ERAS protocol for ureteroscopic stone treatment resulted in a significant reduction in perioperative opioids, a total reduction in discharge opioid prescriptions, and ∼90% reduction in total 30-day postoperative opioid prescribing with no adverse effects on recovery or increase in postoperative clinical encounters.

Kidney stones and the opioid epidemic: recent developments and review of the literature

PURPOSE OF REVIEW

A public health emergency has been declared in response to rising opioid addiction and opioid-related deaths in the United States. As kidney stones have been identified as an important source of initial and repeated opioid exposures, this review seeks to describe the scope of the problem and report relevant alternatives to opioid analgesia for stones.

RECENT FINDINGS

Recent literature summarizing the extent of opioid use among those with stones is reviewed. A number of opioid-minimizing strategies and analgesic regimens have been proposed and studied. A review of these modifications and alternatives is provided.

SUMMARY

Both symptomatic renal colic and surgical interventions to address stones may prompt need for analgesia. Reducing prescribed opioids reduces both patient use and risk of diversion. Modifications in surgical technique, administration of local anesthetics, and use of systemic nonopioid analgesics have all been successfully employed.

New Persistent Opioid Use After Outpatient Ureteroscopy for Upper Tract Stone Treatment

OBJECTIVE

To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery.

METHODS

Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use-defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS.

RESULTS

In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naïve. Nearly 1 in 16 (6.2%) opioid-naïve patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03).

CONCLUSION

Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns.