Urologists Are Helping Combat the Opioid Epidemic, Studies Suggest

NEW ORLEANS -- Urologists are doing their part to try to keep the opioid epidemic under control, according to three studies presented during a press briefing at the American Urological Association (AUA) annual meeting.

Among 6 million kidney stone disease-related emergency department (ED) visits, the proportion of patients receiving opioid prescriptions fell from 33% in 2012 to 16% in 2017, while non-opioid prescriptions increased from 67% to 84%, reported Rajat K. Jain, MD, of the University of Rochester Medical Center in New York.

The odds of receiving an opioid prescription decreased significantly in 2016 and 2017 compared with 2012 (OR 0.27, P=0.01 and OR 0.12, P<0.0001, respectively), they noted, while the odds of receiving a non-opioid prescription increased (OR 2.02, P=0.03 and OR 2.63, P=0.01, respectively).

The researchers used data from the U.S. National Hospital Ambulatory Medical Care Survey to identify ED visits for kidney stone disease from 2012 to 2017. These patients "are uniquely vulnerable to the overuse and abuse of opioids," Jain explained. "And the reason is kidney stone disease is both an acute problem and a chronic problem."

In fact, patients with this diagnosis at their ED visit are the most likely to leave with a prescription for opioids in the U.S., he noted, and data show that the prevalence of opioid use goes up with the number of acute episodes a patient experiences.

While opioid prescriptions peaked nationally in 2012, these rates fell 44% by 2020, a reduction coinciding with the 2016 publication of CDC guidelines on prescribing opioids for chronic pain, and the now standard practice of prescription drug monitoring programs in most states, Jain said.

In a second study, investigators led by Kara Watts, MD, at Montefiore Medical Center in the Bronx, New York, randomized 90 patients undergoing ureteroscopy or percutaneous nephrolithotomy for kidney stones to receive either oxycodone-acetaminophen (Percocet) or the non-opioid ketorolac, and found that the non-opioid strategy was noninferior to opioid pain managment, and was associated with improved pain-reported outcomes by some metrics.

Each of the 90 patients was surveyed by telephone 1 week postoperatively to assess pain outcomes using an 11-point ordinal rating scale questionnaire. Patients in the non-opioid group had significantly lower average scores in several pain-reported outcomes, including:

• Worst pain intensity level: 5.61 with ketorolac vs 7.52 with oxycodone-acetaminophen for a difference of -1.91 (95% CI -3.26 to -0.56, P=0.006)
• Average pain intensity level: 3.34 vs 4.50, for a difference of -1.16 (95% CI -2.26 to -0.06, P=0.040)
• Average pain score: 3.20 vs 4.17, for a difference of -0.96 (95% CI -1.76 to -0.17, P=0.018)

There were also high rates of unused pills after 1 week for both regimens, pointed out Michal Segall, BS, who presented the results. "And this really does continue to suggest overprescription of pain medication and further reinforces the need to re-evaluate pain management practices."

"Opioids should be avoided after elective kidney stone surgery," he concluded. "Our study does add to the growing consensus of the urology community that it is critical to find ways to reduce opioid exposure to our patients and larger communities and this is consistent with the AUA's most recent guidelines for reducing urologic postoperative opioid prescribing."

The third study, presented by Thenappan Chandrasekar, MD, of Thomas Jefferson University in Philadelphia, evaluated a collective effort by four institutions -- Fox Chase Cancer Center, Penn Medicine, Jefferson Health, and Penn State Health -- within the Pennsylvania Urologic Regional Collaborative to reduce opioid prescribing for robot-assisted laparoscopic prostatectomy (RALP).

Overall, 2,061 patients underwent RALP during the course of the study. For the 12 months before protocol implementation, a median of 2.7 oxycodone 5 mg tablets were prescribed to inpatients compared with 2.2 tablets after implementation.

Upon discharge, opioid prescribing was reduced from a median of 20 tablets to a median of 0 tablets, while the percentage of patients who had no opioid use as inpatients but were still given opioids on discharge fell from 98% to 25% (P<0.001).

Despite the decrease in opioid prescriptions, there were no significant changes in pain scores, Chandrasekar reported. On average, 14 fewer opioid tablets were prescribed per RALP, leading to a total of 14,582 fewer opioid tablets in Pennsylvania over a 1-year period.

"Urologists, among other surgeons, play an important role in reducing opioid oversupply and can help combat the opioid epidemic while still providing effective pain management," Chandrasekar concluded.