Discharge Without Opioids Following Percutaneous Nephrolithotomy is Safe and Feasible Using a Nonopioid Pathway
David W. Sobel, MD1, Philip Caffery, PhD2, Evelyn James, MS1, Rebecca Ortiz, BA3, Aidan Peat, BS4, Maximilian Jentzsch, MD5, Erin Santos, MS1, Christopher Tucci, MSN3, Gyan Pareek, MD2.
1Maine Medical Center, Portland, ME, USA, 2Brown University, Providence, RI, USA, 3The Miriam Hospital Minimally Invasive Urology Institute, Providence, RI, USA, 4Tufts University School of Medicine, Boston, MA, USA, 5University of Washington, Seattle, WA, USA.
BACKGROUND Recent studies have demonstrated the success of opioid-sparing pathways for ureteroscopy, however, the feasibility of opioid-free discharge after percutaneous nephrolithotomy (PCNL) has not been evaluated. This study aims to determine the feasibility of a novel nonopioid protocol consisting of enhanced preoperative counseling, multimodal nonopioid analgesics and detailed postoperative instructions. METHODS A prospective feasibility study supported by NIGMS/NIH (P20GM125507) was conducted at a single institution. All subjects underwent single tract 30fr PCNL with urologist access and ureteral stent placement. Control arm subjects received postoperative opioid prescriptions at the discretion of the provider. Patients in the intervention arm underwent preoperative counseling, standardized orders (Figure 1) and specialized discharge instructions. Primary outcomes assessed were discharge without opioid prescription, emergency department (ED) visits for pain, worrisome telephone calls or requests for prescription refills. RESULTS Fourteen subjects were enrolled in the control arm. Of these, 10 (71%) were discharged with opioid prescriptions and 4 (29%) were discharged without opioids. Of the 10 discharged with opioids, 2 (14%) presented to the ED for pain concerns and received a new prescription for opioids. One subject (7%) called the office and was provided reassurance over the phone. No outpatient prescription refills were ordered. Six subjects underwent intervention and received the novel nonopioid protocol. All subjects (100%) in the intervention arm were discharged without opioids. No subjects (0%) presented to the ED for pain concerns. One subject (17%) called the office and was provided reassurance. No new prescriptions for opioids were written. CONCLUSIONS This small feasibility study demonstrates that patients undergoing PCNL via this novel nonopioid pathway can be safely discharged without opioid prescriptions without impact on outpatient resources. Four subjects in the control arm were discharged without opioids based on provider discretion, suggesting that the standard of care to include an opioid prescription may be changing. Larger studies are ongoing to fully evaluate this protocol.
| Control(N=14) | Intervention(N=6) | |
| PRN opioid received on floor (yes) | 10 (71%) | 2 (33%) |
| Scheduled tylenol ordered (yes) | 14 (100%) | 3 (50%) |
| Inpatient intravenous morphine equivalent daily dose (mg/day) Median [IQR] | 4.0 [2.00] | 0 [0] |
| Inpatient oral morphine equivalent daily dose (mg/day) Median [IQR] | 7.5 [2.50] | 16.0 [8.00] |
| Scheduled NSAID ordered (yes) | 7 (50%) | 6 (100%) |
| Most severe pain score during inpatient stay Median [IQR] | 7.0 [3.50] | 6.0 [2.75] |
| Pain score at time of discharge Median [IQR] | 2.0 [3.75] | 2.5 [3.25] |
| No new opioid prescription given at time of discharge | 4 (29%) | 6 (100%) |
| Morphine Equivalent Daily Dose (MEDD) Median [IQR] | 30.0 [10.0] | N/A |
| ED visit within 30 days (yes) | 2 (14%) | 0 [0%] |
| Telephone call to office for pain, GU complaint within 30 days (yes) | 1 (7%) | 1 (17%) |
| Operative reintervention for same nephrolithiasis (yes) | 1 (7%) | 1 (17%) |
| Secondary nonoperative procedure within 30 days not during initial stay (yes) | 0 (0%) | 0 (0%) |
| Request for refill pain medication (yes) | 0 (0%) | 0 (0%) |
| Patient was prescribed an opioid within 30 days (yes) | 2 (14%) | 0 (0%) |
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