Continued Feasibility and Success of a Non Opioid Pathway for Postoperative Pain after Ureteroscopy
Mohannad A. Awad, MD1, David W. Sobel, MD2, Nikolas Moring, MS41, Kevan M. Sternberg, MD1.
1University of Vermont Medical Center, Burlington, VT, 2The Minimally Invasive Urology Institute at the Mariam Hospital, Warren Alpert Medical School of Brown University, Providence, RI.
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 3 year period.
METHODS: Charts of patients who underwent URS with stent placement by a single surgeon from November 2016 to November 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 department (ED) for stent-related symptoms, stent-related clinic telephone calls, and requests for prescription refills for pain medication were measured.
RESULTS: Four hundred and sixty-four patients underwent URS with stent placement over the 3 year period. 38 with reported NSAID allergy or CKD stage II or greater or both were ineligible for the non-opioid pathway and excluded, and 35 were excluded for having other concurrent procedures such as cystolitholapaxy. 391 patients were included in the final analysis. A total of 357 patients were discharged without opioid medications (91.3%). 34 patients received opioids (8.7%). Of those discharged without an opioid, 276 received Diclofenac and 81 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 (3 patients receiving opioids [8.8%] and 26 patients without opioids [7.3%]). Telephone calls made to the urology clinic for concerning symptoms and prescription refills were made by 11 patients receiving opioids (32.4%) and 45 patients without opioids (12.6%).
CONCLUSIONS: More than 90% of patients were able to be discharged without opioids after URS and stent placement over a 3 year period without impact on ED visits, or clinic telephone calls. This was achieved through patient counseling and commitment to change practice patterns. We hope our experience will encourage others to take similar measures to decrease opioid prescriptions in this setting.
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