Leapman MS et al, 2018: Variation in National Opioid Prescribing Patterns Following Surgery for Kidney Stones.
Leapman MS, DeRycke E, Skanderson M, Becker WC, Makarov DV, Gross CP, Driscoll M, Motamedinia P, Bathulapalli H, Mattocks K, Brandt CA, Haskell S, Bastian LA.
Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.
Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Population Health, NYU Langone Medical Center, New York, New York.
VA New York, NY Harbor Healthcare System.
Background: Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis.
Methods: We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose.
Results: We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions: We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.
Pain Med. 2018 Sep 1;19(suppl_1):S12-S18. doi: 10.1093/pm/pny125.
The most devastating pain in urology is colicky pain. But even in this acute situation opioids are rarely given in Europe:
The 2018 EAU guidelines for the management of renal colic state:
“Non-steroidal anti-inflammatory drugs are very effective in treating renal colic and are superior to opioids.
A strong recommendation is “Offer a non-steroidal anti-inflammatory as the first drug of choice. e.g. metamizol (dipyrone); alternatively paracetamol or, depending on cardio-vascular risk factors, diclofenac, indomethacin or ibuprofen.” Opiods should only be offered as a second choice.
The AUA offers relevant information in the 2016 Medical Student Curriculum on Kidney Stones and mentioned narcotics first. “Since most stone patients present with pain, analgesia must also be addressed. Traditionally, narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for pain relief. In most randomized, blinded studies of NSAIDs versus narcotics, NSAIDs have shown equal or greater efficacy of pain relief and a shorter time to reach adequate analgesia with equal or fewer side effects. Nevertheless narcotics seem to be favoured for the treatment of acute and postoperative pain in the US: 80.1% received an opioid prescription in the present series. Usually the immediate post-acute postoperative pain management is the job of the anaesthetists and they may use opioids for a short time if necessary. In the present study ”the median number of days supplied per opioid prescription (IQR) was 10 (5–14).” Obviously this was an outpatient series and the patients must have had relativly pain free. Unfortutnately the study has no information on the patients pain level at discharge.
The last sentence of this publication does not come as a surprise:” Lastly, promise is held in expanding the role of nonopioid analgesics, which may offer improved safety profiles.” I cannot remember to have treated pain in an ambulatory urolithiasis patient with opiods.