Stented URS patients can be discharged without opioids

San Francisco-Discharging patients without opioids for pain control after undergoing outpatient ureteroscopy (URS) with stent placement appears to be feasible, results of a pilot study show.

Conducted by urologists at the University of Vermont, Burlington, the research showed that with use of a decision algorithm for patient selection, adequate counseling, and availability of a prescription nonsteroidal anti-inflammatory drug (NSAID) to alleviate discomfort as needed postoperatively, nearly three-fourths of patients who underwent URS with stent placement were able to be discharged without any opioids.

Furthermore, when looking at the impact on outpatient resources (such as emergency department visits, telephone calls to clinic, and requests for pain medication refills) , those receiving non-opioids were not more likely to visit the emergency department for genitourinary-related concerns (10% vs. 13%, p=.567). Additionally, those receiving non-opioids or no pain medication made significantly fewer telephone calls to the clinic for worrisome symptoms (21% vs. 45%, p=.0006) and made fewer requests for prescription pain medication refills (7% vs. 24%, p=.001).

Among the patients discharged without opioids, approximately 15% did not use any pain medications postoperatively, and those who requested a refill for pain medications were prescribed only an NSAID, reported David W. Sobel, MD, who presented the findings at the 2018 AUA annual meeting in San Francisco. The research was subsequently published in the Journal of Endourology (2018; 32:1044-9).

“We are very excited about these findings showing that patients can be safely and successfully discharged without opioids, and we encourage other urologists to join in the non-opioid revolution,” said Dr. Sobel, urology resident at the University of Vermont.

Read: Nearly 10% of URS patients visit emergency room

“Our pragmatic trial is important because it demonstrates the feasibility of avoiding opioids in this common clinical scenario and can lend support to future explanatory trials,” senior author Kevan M. Sternberg, MD, told Urology Times.

“In addition, the knowledge that most patients can avoid opioids after ureteroscopy and stent placement combined with the known risks of opioids, even in small amounts and for short periods of time, may make a formal RCT difficult to justify,” said Dr. Sternberg, associate professor of surgery at the University of Vermont.

The study included 206 patients identified by retrospective chart review who underwent URS with stent placement between November 2016 and March 2018. Eligibility for discharge without an opioid prescription was determined using an algorithm that excluded anyone with a history of URS requiring opioid pain medications, current opioid tolerance, or renal impairment (chronic kidney disease [CKD] stage ≥II). Of the 206 patients, 151 patients (73%) were discharged without opioid medications based on those criteria.

“In a multivariate analysis, we identified that higher body mass index, CKD, and fibromyalgia were independently associated with receipt of opioids. These findings are not surprising considering that patients were selected for the opioid group if they had CKD or chronic pain,” Dr. Sobel said.

Next: How pathway worksHow pathway works

All patients at the University of Vermont Medical Center undergoing URS with stent placement are managed using an “enhanced stent recovery pathway” that aims to minimize opioid use. Preoperatively, patients are counseled about the reasons for placing a stent, what to expect in terms of stent removal and symptoms, using an NSAID to alleviate postsurgical discomfort, and worrisome signs that should prompt a call to the clinic.

Intraoperatively, all patients without contraindication are given intravenous and postoperative medications that include acetaminophen, 1,000 mg every 6 hours as needed; tamsulosin (Flomax), 0.4 mg once per day; and phenazopyridine, 200 mg three times per day. Patients discharged without an opioid prescription are prescribed diclofenac, 50 mg to be used twice daily as needed for up to 4 days, and they are counseled to try switching to ibuprofen thereafter.

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In the interest of investigating and identifying alternatives to opioids for managing ureteral stent symptoms, the University of Vermont urologists have created the Consortium for Ureteral Stent Pain (www.stentpain.org), through which they aim to enlist the collaboration of urologists, other researchers, patients, industrial designers, and industry partners. As part of the consortium, they have made available an open-source toolkit including the enhanced stent recovery pathway for enabling patient discharge without opioids.

The toolkit includes information on preoperative counseling, the treatment decision algorithm, discharge instructions, and the postoperative medication regimen along with a template for tracking outcomes.