Over the last 2 decades, the United States has lost hundreds of thousands of lives to the opioid epidemic. As the vast majority of the world’s opioids are consumed in the U.S., and deaths continue to rise, new strategies are necessary to limit this crisis. Importantly, providers can address this issue at the ground level. Although several factors, including a lack of awareness and deceptive pharmaceutical marketing, drove this epidemic, prescribers are certainly responsible for inadequately educating and monitoring patients, along with freely prescribing opioids to ensure patient comfort.

Particularly, urology poses an excellent space for progress. Namely, kidney stone patients hold great risk of opioid addiction. This risk is twofold: renal colic is widely prevalent and chronic, but also presents with episodes of acute pain during stone passage or obstruction. Collaboration with other specialties’as emergency medicine and community care physicians may be the first point of contact for urological emergencies or postoperative issues’can improve opioid stewardship.

Prescriptions are a significant gateway in the ability of these dangerous drugs to reach the public. Yet these drugs cannot be completely eliminated in the current environment of drug options. Although over 25% of patients eventually misuse properly prescribed opioids, some patients may fairly require opioids for severe pain. Replacing opioid prescriptions with alternative pain control options whenever possible can mitigate this issue.

Importantly, even when indicated, opioids are notoriously prescribed in greater amounts than necessary. Dispensing extra drugs allows future misuse or community diversion. Ongoing research informing best practices and evidence-based guidelines for opioid use can optimize patient experiences while reducing the potential for addiction and harm.

Accordingly, various research groups demonstrated the feasibility of opioid alternatives at the 117th Annual Meeting of the AUA. Two research groups focused on the relevance of opioid stewardship in renal colic.

Katragadda et al demonstrated that kidney stones are the most common reason for an emergency department (ED) opioid prescription.¹ This shows the surprisingly large role that urology plays in America’s excess opioid use. Thankfully, opioid prescriptions for kidney stones decreased from 33% to 16% from 2012 to 2017, as the odds of receiving an opioid prescription fell (OR 0.12, p ≥0.0001). This downward trend is promising, but more work is required.

Meanwhile, DeMasi et al presented the results of a randomized clinical trial investigating the effectiveness of opioid-free regimens for noninvasive urology procedures, particularly elective ureteroscopy or percutaneous nephrolithotomy.² Overall pain outcomes were noninferior with ketorolac versus oxycodone-acetaminophen. In fact, average pain and worst pain scores were significantly lower with the opioid alternative. Patient-reported pain intensity levels (where 10 is the worst pain) were 5.61 versus 7.52, respectively. By demonstrating preservation of patient comfort and quality of life, this work makes a strong argument for replacing opioids, ultimately reducing addiction risk and community spillover. Notably, this study found that both regimens resulted in high amounts of unused pills, demonstrating an opening for future work.

Although the opioid epidemic has been well-recognized for years, progress has been lacking. The AUA’s 2019 position statement noted that given a quadrupling of opioid use since 1999, stewardship in opioid prescription was necessary. Urologists were encouraged to use the lowest dosage of these drugs when indicated. Additionally, the AUA recommended implementation of prescription drug monitoring programs to monitor use and decrease fraud. Finally, surplus medication reduction was underscored, as the majority of patients who receive opioids are given more than needed for their pain control period.

Although this position statement recognized the vast need for change and provided urologists a paradigm in which to improve care, progress has still been lacking, likely because clear guidelines on indications and dosages are missing. This limits urologists’ ability to consistently affirm appropriate settings for opioid use.

For instance, in 2018 the Mayo Clinic implemented a maximum opioid prescription for tiers of urological procedures. This protocol reduced oral morphine equivalents from 150 to 0. These promising results highlight the utility of clear protocols. Similar work nationally, informed by recent research, can allow urology to take a leading role in addressing the epidemic.

Firm guidelines must be produced by an expert committee to agree upon dosing, indications and evidence-based alternatives. Chart alerts when ordering opioids, along with reminders to follow up with patients who have been discharged with these drugs, can also play a role. Finally, increased awareness amongst providers and patients alike can heighten the impact of the robust research that is being performed to define opioid-safe urological care.

Frontline providers, including ED physicians and advanced practice providers, often serve as the first point of contact for many patients presenting with sequelae from lack of stone passage or painful postoperative urological conditions. Pharmacovigilance regarding opioid prescribing is essential and should be shared amongst all decision-making providers. Evolving practices to mitigate opioid addictions should be part of training not only prior to beginning clinical practice, but also as continuing medical education. Urologists should communicate their findings with other members of the care team to affect change.

Alternative approaches to treating pain associated with renal colic should begin with consideration for prescribing an NSAID (nonsteroidal anti-inflammatory drug) unless clear contraindications exist. Patients in the ED can also be treated with intravenous lidocaine, ketamine, intravenous Tylenol^® or Toradol^®. Unless contraindications exist, a 3-day supply of an opioid for breakthrough pain is certainly a consideration, but assuming normal renal function, the choice is clear to utilize alternatives to opiates such as NSAIDs, like meloxicam, pregabalin, or gabapentin. Future study of ED revisit or admission rates is warranted to clarify these guidelines.

As mentioned, future avenues in which urologists can help fight the opioid crisis involve postoperative pain. A third relevant AUA study involved the Pennsylvania Urologic Regional Collaborative (PURC), a multicenter group which is testing ways to improve health care quality in urology. Chandrasekar et al demonstrated preserved pain control and patient comfort without opioids following robotic prostatectomy.³ Pain scores did not change following protocol implementation, which resulted in 14,582 fewer opioid tablets over 1 year. Median oxycodone tablet prescriptions for inpatients fell from 2.7 to 2.2, while prescribing at discharge reduced from 20 to 0 tablets. Overall, patient outcomes remained consistent while community opioid availability drastically fell. This work demonstrates the potential for diverse institutions to implement rigorous standards which reduce patient risk while maintaining comfort and outcomes.

Ultimately, research such as these AUA studies needs to be elevated to raise awareness amongst providers’not only urologists, but also community care and ED-based prescribers. Evidence-based guidelines demonstrating patient comfort and positive outcomes with opioid alternatives are the strongest way to encourage opioid stewardship.