New England Section of the American Urological Association

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Continued Feasibility and Success of a Non-Opioid Pathway for Postoperative Pain after Ureteroscopy
David W. Sobel, MD, Nikolas A. Moring, MS, Mohannad A. Awad, MD, Kevan M. Sternberg, MD
University of Vermont, Burlington, VT

BACKGROUND: The opioid crisis continues to be a major focus in the United States. The contribution of physician prescribing patterns and the need for improvement in the medical community have been increasingly addressed in the literature. We have previously reported on the feasibility of implementing a non-opioid protocol for outpatient ureteroscopy (URS) with stent placement. Our initial experience demonstrated the success of a non-opioid approach for pain control and stent-related symptoms. In this study, we report our extended experience over a 26 month period.
METHODS: Charts of patients who underwent URS with stent placement by a single surgeon from November 2016 to February 2019 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 received similar adjunct medications including tamsulosin, tylenol, and pyridium. Patients with an allergy to NSAIDs or CKD stage II or greater were excluded from the non-opioid pathway as they were unable to be prescribed NSAIDS. Frequency of postoperative adverse 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 were measured.
RESULTS: Three hundred and sixty-three patients underwent URS with stent placement over the 26 month period. 31 with reported NSAID allergy or CKD stage II or greater or both were ineligible for the non-opioid pathway and excluded, and 32 were excluded for having other concurrent procedures such as cystolitholapaxy. 300 patients were included in the final analysis. A total of 271 patients were discharged without opioid medications (90.3%). 29 patients received opioids (9.7%). Of those discharged without an opioid, 216 received diclofenac and 24 received no pain medication (opioid or prescription NSAID). Both patients receiving opioids and non-opioids had a low number of postoperative visits to the ED for genitourinary-related concerns (2 patients receiving opioids [6.9%] and 23 patients without opioids [8.5%]). Telephone calls made to the urology clinic for concerning symptoms were made by 11 patients receiving opioids (37.9%) and 45 patients without opioids (16.6%). The number of pain medication refill requests was low for both groups: 13 patients receiving opioids (23.6%) and 11 patients without opioids (7.3%). CONCLUSIONS: Our experience using a non-opioid pathway after URS and stent placement reveals that approximately 90% of patients can be discharged without opioids. Patients had a low number of visits to the ED for postoperative genitourinary symptoms, a low number of telephone calls to the clinic, and requested few pain medication refills regardless of whether or not they received opioids on discharge. We hope our experience will encourage others to reduce opioid prescriptions in this population in the future.


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