Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. Among those presenting with symptomatic nephrolithiasis, patients electing for trial of passage with medical expulsion therapy were more likely to receive a prescription for an opiate compared with those electing for early surgical intervention.

Evidence Rating Level: 3 (Average)

Despite a widespread reduction in the number of prescriptions for opioids in the U.S., the number of emergency department visits for opioid overdoses continues to remain high, particularly in the Midwest. Opioids are commonly prescribed to patients with nephrolithiasis for pain control; in fact, between 2007 and 2014, opioid use among individuals with a history of nephrolithiasis was significantly higher compared with those without. This retrospective cohort study examined 135 patients with symptomatic nephrolithiasis managed with either trial of passage (TOP) with medical expulsion therapy (MET) or with surgical intervention, consisting of either primary ureteroscopy (n = 27, median [IQR] age = 51 [33-63] years, 44.4% female) or staged ureteroscopy with ureteral stenting (n = 39, median [IQR] age = 52 [35-68] years, 53.8% female). Patients electing for TOP were further grouped into successful TOP (n = 30, median [IQR] age = 36 [31-51] years, 50% female) and unsuccessful TOP requiring subsequent ureteroscopy (n = 36, median [IQR] age = 47 [36-60] years, 52.8% female) or staged ureteroscopy with ureteral stenting (n = 3, median [IQR] age = 57 [50-64] years, 0% female) cohorts. It was found that patients who elected for initial TOP were significantly more likely to receive a prescription for an opiate compared with those treated with stenting or primary ureteroscopy (60.9% vs. 35.9% vs. 33.3%, p = 0.01). Furthermore, all three TOP cohorts were significantly more likely to receive a prescription for an opiate than both primary surgical intervention cohorts (p = 0.008). In all, this study suggests that patients electing for TOP with MET were more likely to receive an opiate prescription compared with those electing for early surgical intervention. Urologists should keep these findings in mind during shared decision making with the patient, though a robust prospective study should be done to further clarify these data.

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