Abstract
Managing postoperative pain in today's environment is challenging and frequently places physicians between a rock and a hard place. But there is a reason we are in this present situation. A 1980 NEJM letter to the editor concluded that patients treated with narcotics rarely go on to dependancy. 1 In the 1990s, the American Pain Society called for improved identification and treatment of pain. 2 Pain became the fifth vital sign and in 1995 quality improvement guidelines for the treatment of acute and cancer pain were published. 2 In 2000, JAMA published JCAHO pain management standards that became part of the hospital accreditation process and used as a performance metric for health centers. 3 In addition Centers for Medicare and Medicaid Services included several questions about the adequacy of pain control during hospitalization as part of their Hospital Consumer Assessment of Healthcare Providers and Systems survey. 4
Unfortunately in the spirit of compliance, the pendulum has swung the other way where overprescribing opioids became the norm. 5,6 Fast forward to today where we are seeing epidemic levels of narcotic addiction and opioid-related deaths. 7,8 Where is the happy medium in managing pain? No physician wants anyone to suffer, yet at the same time no physician wants to be the cause of someone's dependence on pain medication. Never is this dilemma more obvious than in managing patients with stone disease.
This article is quite timely, as it tries to make sense of the present problem by identifying those patients at risk post-ureteroscopy who go on to prolonged opiate use. The authors demonstrated that 12% of patients required an additional opioid prescription within a 30-day period postoperatively. Long-term usage was lower with only 7% filling prescriptions >60 days postoperatively. Risk factors were younger age and high preoperative usage. They also demonstrated that such individuals with prolonged use obtained more than three prescriptions preoperatively and from multiple providers.
What we learn from this is to pay attention to preoperative narcotic usage especially in younger patients. Keep postoperative prescriptions to a minimum and augment with non-narcotic medications whenever possible. 9 Even more importantly, preoperative education and setting realistic patient expectations have shown to markedly decrease postoperative opioid usage. 10,11 When patients know what to expect they can usually deal with it. With the mentioned combination, hopefully the pendulum will start to swing the other way toward better pain care without the epidemic of opioid dependence or related deaths.