Trends in Acute Pain Management for Renal Colic in the Emergency Department at a Tertiary Care Academic Medical Center

Abstract

Introduction: Renal colic secondary to kidney stone disease is a common reason for emergency department (ED) visits and often leads to patients receiving narcotic medications. The objective of this study was to describe longitudinal analgesia prescribing patterns for kidney stone patients acutely managed in the ED. Methods: This was a retrospective chart review of patients who presented to the ED between 2013 and 2018 and were subsequently diagnosed with a kidney stone. Encounters during which opioids and nonopioids were administered in the ED and prescribed at discharge were stratified by year, race, ethnicity, insurance status, gender, and location of ED (main academic campus and community-based campus). Patients were excluded if they required hospital admission or a stone-related procedure related to the ED encounter. Results: We reviewed 1620 total encounters for 1376 unique patients. Frequency of patients receiving opioids in the ED decreased from 81% in 2013 to 57% in 2018 ( p < 0.001). During the same time period, nonopioid administration in the ED remained relatively unchanged (64% vs 67%). The proportion of patients prescribed opioids at discharge decreased from 77% to 59% ( p < 0.001), while nonopioid prescriptions at discharge increased from 32% to 41% ( p = 0.010). Frequency of administering both a narcotic and non-narcotic during the same ED encounter decreased over the 5-year period from 27% to 8% ( p < 0.001). Conclusion: Opioids are being given less both during the ED encounter and at discharge for acute renal colic, while nonopioid prescribing is increasing. These trends may be due to increasing physician awareness to opioid addiction, or as a result of stricter legislation prohibiting opioid prescribing.

Opioid Analgesic Use After an Acute Pain Visit: Evidence from a Urolithiasis Patient Cohort

“…The difference in the proportion of patients receiving an opioid analgesic prescription between this study and that in Cotta et al 12 could be due to several factors: variation in prescribing between hospitals (within hospitals in this study 52-95% of visits received an opioid analgesic prescription); our sample of ED visits (Cotta et al noted that patients with an initial visit to the ED were more likely to receive a prescription than if the initial visit was at an urgent care or another clinic type) 12 ; and finally, a possible decrease in prescribing over time, although this change has been found to be minimal for urolithiasis compared to other contexts. [17][18][19] Consistent with our results, the retrospective study found that those who received an opioid analgesic prescription at their initial visit were more likely to require a refill during the acute stone episode than those who did not receive an opioid prescription at the initial visit.…”

“…17 For the years 2013-2018, other individual EDs reported decreases from 70% to 52% 19 and from 81% to 59%. 18 Had the present investigation been repeated in 2018, we would expect to see fewer than 79.6% of urolithiasis patients receive an opioid analgesic prescription at ED discharge, likely close to the 59% observed in the Kominsky et al study. 18 However, we do not have reason to expect the relationship between opioid analgesic prescribing and use to change over time.…”

“…18 Had the present investigation been repeated in 2018, we would expect to see fewer than 79.6% of urolithiasis patients receive an opioid analgesic prescription at ED discharge, likely close to the 59% observed in the Kominsky et al study. 18 However, we do not have reason to expect the relationship between opioid analgesic prescribing and use to change over time. Hence, we believe these results remain applicable to current ED practice.…”

“…16 However, decreases in prescribing for severe acute conditions, such as urolithiasis, have been relatively small in comparison to the overall decrease in prescribing. [17][18][19] While opioid overdose deaths had previously begun to decrease, they became higher than ever during the COVID-19 pandemic. 20 There is evidence that even a one-time prescription for an opioid analgesic may result in long-term opioid use after a dental procedure, 21 pregnancy, 22 and ED visits for back pain 23 or ankle sprains, 24 but this has not been studied for patients with urolithiasis, a condition characterized by severe acute pain.…”

“…However, opioid analgesic prescribing for acute painful conditions such as urolithiasis has decreased very slowly compared to overall prescribing. [17][18][19] In this patient population, 79.6% (n = 710) of patients with urolithiasis received an opioid analgesic prescription at ED discharge. This is higher than national estimates for 2012-2013, when 56.9% of urolithiasis patients received an opioid analgesic prescription at ED discharge, and for 2016-2017, when the national estimate was 49.2%.…”