Opioids remain an important analgesic agent for almost all urologists. Acute ureteral colic, in particular, can generate such intense and intractable pain that opioids may be required, even for patients with known opioid dependence or misuse.
The problem for the urologist is finding a way to balance appropriate acute pain relief with the recognized risks of opioid dependence and overdose.
“We know that younger people — young men in particular — and people with a history of chemical dependency, poly drug abuse, severe depression or psychotropic medications have an increased risk of opioid dependency,” said Deborah Lightner, MD, professor of Urology at Mayo Clinic. “As we are often seeing them for the first time for an acute stone event, it’s often difficult for the urologist to assess a patient’s risk of chemical tolerance or to appropriately manage their acute pain without increasing the likelihood of an opioid complication. At the same time, we need to ensure adequate pain relief.”
Dr. Lightner will moderate Friday’s 40-minute Court is in Session: Benign: Opioid Overdose in Patient with Chronic Flank Pain presentation, which begins at 1:35 pm during the Prime Time plenary session in the Esplanade Ballroom at Moscone South. The mock court case centers on a young male opioid-tolerant patient with multiple, recurrent stones who presented acutely with intractable pain. Despite prior exposure to opioids, the patient experienced an overdose.
The defendant in the fictionalized case is Arthur Smith, MD, professor of Urology at Hofstra University. His expert witness is Glenn Preminger, MD, professor and Chief of Urology at Duke University Medical Center, and the expert witness for the plaintiff is Gregory Auffenberg, MD, MS, clinical instructor in Urologic Oncology at Memorial Sloan Kettering Cancer Center.
Opioids are almost never used as monotherapy for the management of acute pain due to renal or ureteral colic, Dr. Lightner noted. Multimodal analgesia can provide similar pain relief with less risk for opioid misadventure, and typically includes the use of scheduled nonsteroidals such as acetaminophen or ibuprofen, and neuroleptic modulators such as gabapentin used periprocedurally in place of opioids. Furthermore, opioids should never be prescribed beyond the immediate perioperative period.
“Current best practices include limiting opioid prescriptions to ensure that patients have only enough medication to last through the immediate postoperative period. If the offending stones have been managed appropriately, pain should decrease quickly following treatment. If the patient experiences prolonged intractable pain after the initial treatment, the urologist should suspect a recurrence, a persistent stone or another cause, including chemical dependency,” Dr. Lightner said.
Stent pain is almost never treated with opioids, she added. Antispasmodics and alpha blockers are the most commonly used agents for patients who have painful stents.
The need to prescribe opioids for acute pain in stone disease is a particular problem in patients who are already opioid tolerant. Opioid tolerance is not an absolute contraindication to opioid use because there may be no other effective analgesic. But existing opioid tolerance or chemical dependency, or prior opioid use is a warning sign for potential complications associated with acute pain management.
“We will discuss a case of significant bilateral upper tract stone disease associated with chronic flank pain, which will emphasize the difficulty of managing acute pain in patients with chronic pain,” Dr. Lightner said. “The malpractice case will examine if the opioid overdose was preventable or a predictable risk of management, and whether the defendant could have done things in a more appropriate manner to avoid the overdose.”