Urological surgery has played a role in the perpetuation of the opioid epidemic in the United States. Pain control after commonly performed endourological procedures for kidney stones has contributed to the pervasive overuse of opioid medications. This fact is supported by a recent study demonstrating that nearly 1 in 16 opioid-naïve patients develop new persistent opioid use after ureteroscopy for nephrolithiasis.¹ Due to increased awareness of the opioid epidemic, urologists have begun to address their own practice patterns regarding postoperative pain control. Multiple feasibility studies have demonstrated that most patients can be discharged without any opioid prescriptions after outpatient ureteroscopy with no impact on outpatient health care utilization.^2,3

On a positive note, it appears that the successes shown from early experiences have persisted. An updated review of the experiences at the University of Vermont has shown that over a 3-year period, >90% of almost 400 patients undergoing ureteroscopy with stent placement were successfully discharged without opioid prescriptions. Not receiving an opioid did not appear to increase health care utilization through emergency department visits or telephone calls to clinic. A recent study by Lee et al found that by following a nonopioid pathway after ureteroscopy, new persistent opioid use occurred in only 1% of patients.⁴

Newer studies have strengthened earlier observational findings by formally comparing the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) to opioids after ureteroscopy. Fedrigon et al at the Cleveland Clinic just released the results of SKOPE (Study of Ketorolac vs Opioid for Pain after Endoscopy), a double-blinded randomized control trial in patients undergoing ureteroscopy, which showed noninferiority of NSAIDs compared to opioids.⁵ The study also showed improved recovery time in the NSAID group. While it can be difficult to alter practice patterns based on small, single-center, observational experiences, this study is anticipated to more broadly reinforce the finding that NSAIDs are not inferior to opioids for managing post-ureteroscopy pain and should more broadly impact clinical care.

While results from single-institution series highlight the feasibility and safety of an opioid-free pathway following ureteroscopy, how this will be translated into general urological practice is less clear. A good example of such an effort can be found in the Michigan Urological Surgery Improvement Collaborative’s Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) initiative. This collaborative quality improvement initiative, funded by Blue Cross Blue Shield of Michigan, includes more than 90% of urologists in Michigan. Due to its diverse practice inclusion, MUSIC ROCKS serves as a generalizable sample of wider urological practice. Started in 2016, MUSIC ROCKS has focused on myriad issues surrounding optimization of ambulatory stone surgery outcomes. A key focus has been opioid stewardship after ureteroscopy. By discussing strategies for reducing opioid utilization at statewide meetings, creating a widely adopted pain optimization pathway (POP; fig. 1) as well as offering incentive-based payment programs (MUSIC POP [MPOP]), rates of opioid prescription have seen an absolute decline of more than 70% following ureteroscopy (fig. 2).

Figure 1. POP for ureteroscopy utilized in MUSIC ROCKS collaborative in Michigan.

Figure 2. Trend in opioid prescribing following ureteroscopy in MUSIC ROCKS from 2016 to 2020. Included within figure is initiation of POP and MPOP.

Despite this apparent success, there remains substantial variation among individual providers within MUSIC ROCKS with respect to opioid prescribing, which indicates continued room for improvement (fig. 3). Moreover, although recommendations indicate that NSAIDs should be first line therapy for pain control following ureteroscopy, only approximately a third of patients are prescribed these agents following surgery, which represents a potential missed opportunity.

Figure 3. Provider-level variation in opioid prescribing following ureteroscopy in MUSIC ROCKS. URS, ureteroscopy.

Pain management in the acute setting is also important to consider. Renal colic is one of the most common presenting symptoms seen in the emergency department and necessitates prompt symptom control. NSAIDs have been shown to be equally if not more effective when compared to opioids in this setting.^6,7 In addition, studies have shown that exposure to opioids prior to surgical stone intervention increases the risk of persistent opioid use. Addressing pain control in the acute setting may be instrumental in reducing opioid use downstream during the stone episode.

So, are we winning the battle? We are certainly off to a strong start, but the war is not over. The national opioid prescribing rate has declined significantly from a peak in 2012 to 2019.⁸ In general, the increased awareness and focus on the opioid epidemic in our country have resulted in successful efforts to decrease opioid prescribing. However, the COVID-19 pandemic appears to have had a negative effect on the progress made in reducing opioid prescribing. Researchers at Brown University have seen increased opioid prescriptions following evaluation for renal colic in the emergency department during the initial pandemic period.

While we cannot answer the question completely, it is likely that opioid prescribing for patients with kidney stones has decreased but remains variable. This results from several challenges that exist plus the fact that culture in general is difficult to change. First, patient factors, including preexisting anxiety and depression and chronic pain, make it difficult to avoid opioids after stone surgery.⁹ Second, patients may receive opioid prescriptions from other physicians besides their surgeon. For example, Lee et al found that 16.6% of the 239 patients following a nonopioid pathway after ureteroscopy ultimately received an opioid prescription within 31 days of the surgery and that these were primarily obtained from alternative providers.⁴ Third, opioid prescriptions are often given for renal colic by emergency medicine providers or primary care physicians, and this can make it more difficult to avoid such medications postoperatively. Fourth, practice structure, location, and local legislation around opioid prescribing all impact practice patterns. These factors can present a challenge to the patient sent home without opioids who still experiences pain and cannot obtain an opioid prescription. “Just-in-case” prescriptions can be difficult to avoid in such scenarios.

Finally, defining our goals is important. It is easy to preach that opioids should be completely avoided in all patients with kidney stones or after stone related surgery. While most patients can be managed well without opioids, there are some who cannot, and this needs to be acknowledged and not seen as a failure on the part of the prescribing physician. That being said, a true effort is needed to change the culture surrounding pain management norms and practices to get closer to the goal of opioid avoidance for most.