15 Month Experience with a Non-Opioid Pathway for Postoperative Pain after Ureteroscopy
David W. Sobel, MD; Theodore Cisu, MS4, Andrew Pham, MS2, Kevan M. Sternberg, MD
University of Vermont, Burlington, VT
BACKGROUND: In light of the American opioid epidemic, efforts have begun to implement non-opioid protocols for outpatient urologic surgery. Previously, we reported our initial six month experience demonstrating that ureteroscopy (URS) with stent placement is possible without postoperative opioids for pain control and stent-related symptoms. In this study, we report our 15 month experience demonstrating the continued feasibility of a non-opioid discharge pathway compared to standard opioid medications for postoperative pain following URS and stent placement.
METHODS: Charts of patients who underwent URS with stent placement by a single surgeon over a 15 month period from November 2016 to March 2018 were retrospectively reviewed. During this time period, efforts were made to substitute opioid pain medications on discharge for either no prescription or diclofenac, an NSAID. All patients having normal renal function and no evidence of current or prior opioid tolerance were eligible for the non-opioid protocol. Feasibility was evaluated by measuring the frequency of postoperative events including visits to the emergency room (ER) for stent-related symptoms, stent-related clinic telephone calls, and requests for prescription refills for pain medication in the opioid and non-opioid groups.
RESULTS: 206 patients underwent URS with stent placement: 151 patients were discharged without opioid medications (73.3%) and 55 received opioids (26.7%). Of those discharged without an opioid, 129 received diclofenac and 22 received no pain medication. The majority of patients received adjunct medications such as tamsulosin (71.4%) and phenazopyridine (75.2%) on discharge. A similar percentage of patients receiving opioids and non-opioids had postoperative visits to the ER for genitourinary-related concerns (7 patients receiving opioids (12.7%) and 15 patients without opioids (9.9%); p=0.567). Patients in the non-opioid group made significantly fewer telephone calls (25 patients receiving opioids (45.4%) and 32 patients without opioids (21.2%); p=0.0006). The number of pain medication refill requests was also significantly fewer among patients given non-opioids, as compared to patients given opioids (13 patients receiving opioids (23.6%) and 11 patients without opioids (7.3%); p=0.001).
CONCLUSIONS: Our experience using a non-opioid pathway post ureteroscopy and stent placement reveals that approximately 3/4 of patients can be discharged without opioids. Compared to patients receiving opioids, patients receiving non-opioid therapies had similar postoperative adverse events with overall lower impact on outpatient resource utilization. We intend to further elucidate the patient characteristics leading to the necessity for opioids after ureteroscopy in a future subgroup analysis.
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