Abstract
This article is timely and deals with a subject of significant importance to all physicians managing patients with urinary calculi. Based on the Centers for Disease Control and Prevention database, 130 people are dying every day in the United States from opioid overdose. It is also estimated that 40% of these >40,000 overdoses per year were attributable to prescription opioids. 1 Administration of opioids by physicians treating kidney stones significantly contributes to this problem. After any opioid prescription, the rates of continued opioid utilization may vary between 6% and 30%, depending upon the amount of opioids prescribed and other patient-related risk factors. 2
This article offers a unique solution to this difficult problem. At Vanderbilt University, Gridley et al. 3 implemented a multimodal quality improvement pathway as part of an enhanced recovery after surgery protocol for patients undergoing ureteroscopic lithotripsy and stent placement. This protocol began with careful and detailed counseling about the risks of narcotics by both the urology and anesthesia teams to appropriately set patient expectations. Narcotics were minimized or eliminated in the preoperative, intraoperative, perioperative, and postoperative phases of patient care. Preoperatively, patients were given acetaminophen and gabapentin. Intraoperatively, the authors used ketamine, lidocaine, and ketorolac, whereas in the recovery room patients were given tramadol first line and oxycodone and hydromorphone as backup. Finally, at discharge, patients were given no narcotics, but instead received acetaminophen, ibuprofen, and tamsulosin. The authors routinely used a small 4.8F ureteral stent in the majority of patients to further minimize pain.
Implementation of this protocol resulted in >90% of patients discharged without any narcotics in the postoperative period. This narcotic-free recovery was accomplished with no increase in patient phone calls or clinic visits. These impressive results are in harmony with other recent studies demonstrating that narcotics can be avoided in the majority of ureteroscopy patients. 4,5
As the authors acknowledged, the limitations of this study include a relatively small sample size with somewhat heterogeneous groups (sex and prior chronic opioid use) although these were not statistically different. In addition, after protocol implementation, patients had higher pain intensity scores and interference with daily life as suggested by postoperative the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity 3a, and PROMIS Pain Interference 6b questionnaire scores. However, this did not decrease overall quality of life. This raises the question, how much postoperative pain is acceptable? It seems intuitive that a small increase in pain during the perioperative period is acceptable to avoid long-term narcotic addiction. In addition, this protocol implemented many changes and it is difficult to know which steps were essential to avoid postoperative narcotic usage. In the future, it may be possible to prospectively implement simpler protocols that may still accomplish these same excellent results.