Narcotics-free ureteroscopy: Anatomy of an ERAS protocol

In this interview, Nicole L. Miller, MD, discusses her institution’s enhanced recovery after surgery protocol for ureteroscopy, which eliminates the use of opioids in patients undergoing this common procedure.

Opioid abuse continues to be a problem in the US, with 14,139 deaths involving prescription opioids reported in 2019.1 One way health care providers are addressing this issue is by treating pain from surgical procedures differently. In this interview, Nicole L. Miller, MD, discusses her institution’s enhanced recovery after surgery (ERAS) protocol for ureteroscopy, which eliminates the use of opioids in patients undergoing this common procedure. Miller is a professor of urology at Vanderbilt University Medical Center, in Nashville, Tennessee.

How did you come to identify ureteroscopy as a procedure for which to create a narcotics-free protocol?

Patients with kidney stones have a painful condition that’s typically recurrent, so they visit emergency rooms and acute care clinics regularly. At every point of care, there is the potential that they will be prescribed pain medications, and opioids have traditionally been used for this type of pain. We felt this patient population had an opportunity not only for increased opiate use but also for repeated exposure. Studies have shown that the risk of persistent use in opioid-naïve patients following ureteroscopy is 6.2%, or 1 in every 16 patients.

When patients with kidney stones need surgery, we typically put in a ureteral stent after the procedure. Many patients tell us that the stent is the most uncomfortable part of the operation. Traditionally, we thought that we needed opioids to control pain related to the stent. But the opioid crisis in the US made us begin to question whether this was true. As we evaluated our prescribing practices, it became more evident that much of it was based on habit rather than need.

Ureteroscopy seemed like the obvious procedure to test the hypothesis that we could reduce or even eliminate opioids because we could evaluate these patients during the short time during which the stent was in place and record adverse events, symptoms, presentations, and acute care visits.

Please briefly walk through the narcotics-free protocol for ureteroscopy.

Vanderbilt as an institution has implemented ERAS protocols for many different operations. These are intended to be patient-centered, evidence-based, multidisciplinary team-developed protocols to optimize physiologic function and facilitate patient recovery. I’m making a distinction between protocol and enhanced recovery after surgery to emphasize our desire to not only decrease opiate exposure postoperatively but also to examine every phase of care to improve the entire operative experience.

Patients undergoing ureteroscopy with ureteral stent placement are given acetaminophen (650 to 1000 mg) and gabapentin (100 to 300 mg) in the preoperative holding area. Gabapentin, which acts on the nociceptive processes involved in central sensitization, has been shown to reduce postoperative pain and opioids use during the first 24 hours after surgery.

In the operating room, the patient is given a belladonna and opium suppository per rectum to treat stent-related bladder discomfort and the nonsteroidal anti-inflammatory medication Ketorolac. Typically, we give 30 mg of Ketorolac intravenously if the patient has normal renal function. We will reduce it to 15 mg if renal function is at all compromised. In randomized trials, nonsteroidal anti-inflammatory drugs have been shown to be superior to opiates for renal colic, so if you had a choice between giving patients in the emergency room ketorolac or morphine, they actually did better and required less pain medication with the nonsteroidals. Using Ketorolac intraoperatively allows us to target the prostaglandin-mediated pain pathway that’s involved in kidney and ureteral stent-related pain.

The anesthesia team gives minimal or often zero intraoperative opioids, and in the recovery room opioids are only given if the patient has breakthrough pain. In that case, a single IV dose of hydromorphone 0.25 mg or an oral dose of oxycodone 5mg may be given.

Many of the published studies on opiate reduction in kidney stone patients have focused on postoperative prescribing. We used to standardly prescribe a 5- to 7-day course of opiates to last until the ureteral stent was removed. Considering these medications are typically taken every 6 hours, these prescriptions could be 20 to 28 pills at minimum.

A real problem is what happens to unused opioid medications, many of which are consumed by someone other than the patient, are sold for profit, or result in accidental exposure to children. The postoperative portion of our ERAS protocol is certainly where we have made the most change. For most patients, no opioids are prescribed. We use a 4-medication regimen as our standard protocol. Patients are instructed to take acetaminophen 1000 mg every 8 hours, alternating with ibuprofen 800 mg every 8 hours. We want them to alternate between the Tylenol and the ibuprofen so that there’s something they can take for pain every 6 to 8 hours. Two additional medications, tamsulosin and oxybutynin, are meant to combat the stent-related discomfort. In a randomized controlled trial, tamsulosin was shown to improve stent pain and oxybutynin to decrease bladder spasms. Patients are prescribed tamsulosin 0.4 mg daily and oxybutynin XL 10 mg until stent removal. In choosing these 4 medications, we are providing multimodal analgesia. We are targeting different pain pathways to improve the patient experience, decrease pain, and reduce opiate exposure.

What effects have you seen by introducing the ERAS pathway at your institution?

One thing that’s been incredibly positive is improved communication among providers because everyone is focused on the same outcome, which is for the patient to have the best experience, but also to understand we’re implementing these protocols in order to decrease opiate prescribing and to combat the crisis in this country. We now understand that the risk of developing persistent use is associated with how much we prescribe. There have been multiple studies showing that the more opiates we give patients at the time we prescribe them, the more likely they are to be at risk for persistent use. I think everyone understands that, and so among the nursing team, the anesthesia team, and the surgery team, there’s much better collaborative management and ownership of patient outcomes. We are all working from the same protocol and have the same goals.

What sorts of challenges were involved in implementing this pathway?

Many patients have had kidney stone surgery before, and they remember that when they had a stent, they had pain. When you tell them that you’re not going to prescribe opiates, patients often worry that they will have uncontrolled pain. Educating the patient and all the care providers is crucial. We explain to the patient that our goal is not to make them pain-free, but rather to control their pain so that they’re able to perform the activities of daily living. We give them information about the risks of using opiates. We make it clear that they can contact a urology provider 24/7 and that there is an escalation protocol in place for breakthrough pain.

We’ve found that what was initially challenging has now been widely accepted by patients. I think there’s enough information in the news that patients are afraid of opiates. Previously, patients expected to receive opioids postoperatively, but now many of them actually say, “I don’t want you to give me any opioids. Is there anything else I can take?”

Tennessee has been pretty forward-thinking in terms of legislation. Around the time we started introducing these protocols, they instituted prescribing guidelines limiting the amount and duration of opioid prescriptions. In addition, we have a controlled-substances monitoring database in the state that allows us to obtain detailed patient-specific information on controlled substances prescribing. I think the combination of patient awareness about prescribing laws and education surrounding opioids has made it easier for patients to understand why we are changing our practice patterns.

What advice would you give to other practices that might like to implement this sort of pathway?

I would say do it and don’t look back. It will require some commitment and collaboration. The first step is to know your prescribing data; you need to know where you’re starting from. It could be that you’re prescribing opioids based on what you’ve always done rather than what is actually needed. It’s also important to see what variations you have in prescribing opioids and whether they are appropriate. One of the things the literature has shown is that we don’t often prescribe based on the procedure we’re performing. Ureteroscopy is a fairly minimally invasive procedure, and yet some patients have been prescribed as much opioid as they would if they had had a more invasive, open surgery. I’m not saying we should never prescribe opioids, but I do think that we need to be thoughtful about prescribing.

Once you know your prescribing data and implement prescribing changes, you have to follow the outcomes. I highly recommend doing that because I think the fear when you institute a protocol like this is that acute patient visits and episodes of care will increase, putting a strain on providers, clinics, and institutions. We have not really seen that. Once you know your prescribing data, make the change, and monitor the outcome, you can feel very comfortable that your efforts will be successful. In addition, the American Urological Association has recently released a position statement on opioid use that is an excellent resource for clinicians.2

Is there anything else that you feel our audience should know?

It’s really important to know what is going on in your state. You need to understand what legislative measures are being taken; you need to know whether there is a controlled-substances monitoring database. If there is, you should be using it to monitor your patients. Another thing we’ve seen and published on at Vanderbilt is that patients often get narcotics from more than one prescriber, which has been described as postoperative “doctor shopping.” So you may not be giving opioids to your patients, but someone else might be. You have to look at the patient as a whole. Here is where controlled-substances monitoring databases are really useful. And make sure that everyone is aligned to the same goal: the patient undergoing the procedure, the anesthesia team giving medications intraoperatively, the nursing staff treating patients and reporting their pain scales. Everyone needs to be communicating well with one another. If you can do that, this can be incredibly successful. I think education of the entire care team as well as the patient is the most crucial factor.

References

1. National Institute on Drug Abuse. Overdose death rates. January 29, 2021. Accessed September 1, 2021. https://bit.ly/3gOdygs

2. American Urological Association. AUA position statement: opioid use. Updated January 2019. Accessed September 1, 2021. https://bit.ly/3uC3FHl