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Review: Opioids and Kidney Stones

Key findings

  • Urology is not immune to the opioid crisis—research has documented overprescribing and a significant risk that patients will use and misuse opioids far into the postoperative period
  • This review discusses the use of opioids in the management of patients with kidney stones, focusing on the treatment of renal colic and pain control after ureteroscopy and percutaneous nephrolithotomy
  • The use of nonsteroid anti-inflammatory drugs, improved clinical pathways for treating ureteral stent discomfort, and local and regional nerve blocks for percutaneous nephrolithotomies have enabled a reduction in opioid use by patients with kidney stones

Opioids traditionally have been used to treat renal colic during the acute passage of kidney stones, as well as for pain management after endoscopic kidney stone surgery. Unfortunately, as in other fields, research has documented routine prescription of opioids after outpatient procedures and provision of excessive doses.

In Seminars in Nephrology, Brian H. Eisner, MD, co-director of the Kidney Stone Program in the Massachusetts General Hospital Department of Urology, Christina Kottooran, an intern in the department, and colleagues review how urologists are limiting opioid use when treating patients with kidney stones, focusing on opioid alternatives and practice patterns that discourage persistent use of these medications.

Renal Colic

Nonsteroidal anti-inflammatory drugs (NSAIDs)—Even in the setting of acute pain from kidney stone passage, NSAIDs alone are sometimes sufficient. Their time of onset is comparable to that of opioids. Diclofenac (typically 50–75 mg IM) and ketorolac (30 mg IM) are equally effective.

Opioids are titratable and confer a broader effect on the central nervous system than NSAIDs do. Pethidine (typically 50–100 mg IM) and morphine (typically 0.1 mg/kg IV) are comparable in efficacy and side-effect profile.

Ketorolac plus morphine is superior to either drug alone for relief of acute renal colic, according to a randomized, controlled trial published in the Annals of Emergency Medicine. The combination required decreased use of rescue analgesia.

Intravenous acetaminophen is an attractive alternative to other NSAIDs because of its more favorable side effect profile. Some studies of its use for renal colic have demonstrated pain relief equal to morphine, and others have shown acetaminophen is superior.

After Ureteroscopy

Several recent studies have explored novel protocols for controlling pain related to post-procedure ureteral stents. One strategy emphasizes preoperative patient education about opioids, intraoperative administration of IV ketorolac (and, in one study, a belladonna and opium suppository), and a multi-medication regimen for postoperative pain.

This research has detected no significant differences between opioids and the nonopioid protocol in outcomes such as telephone calls about pain or eventual requirement for an opioid prescription.

Another strategy is to develop an Enhanced Recovery After Surgery (ERAS) protocol to limit opioid use both intraoperatively and postoperatively. Such a protocol, reported in the Journal of Endourology, was examined in a prospective observational study.

Acetaminophen and gabapentin were used preoperatively, and ketorolac and belladonna opium were given intraoperatively. In the post-anesthesia recovery room, tramadol was the first-line treatment for pain, and opioids were reserved for refractory pain. Acetaminophen, ibuprofen, oxybutynin, and tamsulosin were given at discharge—no patient received a prescription for an opioid.

Fewer than 30% of patients in the ERAS group required opioids in the recovery room, and the total postoperative opioid prescription dose decreased by 87% after the protocol was initiated. Compared with the pre-ERAS group, there was no significant difference in telephone calls for pain, requests for opioids or medication refills, provider encounters for pain, or health-related quality of life measures.

After Percutaneous Nephrolithotomy (PCNL)

Patients often have severe pain after PCNL because of the puncture through the flank into the renal collecting system. Surgeons have been injecting a local anesthetic along the PCNL tract for decades, but some groups are now using ultrasound-guided local nerve blockade to improve analgesia. Intercostal, paravertebral, and other blocks have shown promising results for reducing time to first analgesia requirement and cumulative analgesia consumption.

Learn about the Kidney Stone Program

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