Treatment of Acute Renal Colic in US and French EDs: Simulated Cases and Real Cases in Acute Pain Management

Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy

BACKGROUND AND OBJECTIVES

Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy.

METHODS

A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed.

RESULTS

Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001).

CONCLUSIONS

Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.

Clinician training level impacts prescribing practices for the conservative management of acute renal colic: a contemporary update

PURPOSE

Given the current and increasing awareness of the opioid crisis, this study aimed to characterise the types of analgesic prescription for conservatively managed renal colic.

METHODS

This was a retrospective cohort study of consecutive patients presenting to the Emergency Department (ED) in 2014-2019. Patients were included if they had radiographically confirmed obstructing calculus, managed conservatively without intervention, and were given a prescription for analgesia on discharge. Patient demographics were recorded and analysed. Opioid, non-opioid, and alpha-blocker medications were compared according to patient and disease parameters, and clinician training. Oral morphine equivalents (OMEs) were used to compare prescribed quantities. Subgroup analyses of stone size and location were performed.

RESULTS

Our analysis included 1761 patients with confirmed renal colic: median age of 50 years (16-96). Altogether, 88% of included patients were prescribed opioids on discharge, while only 68% were prescribed non-opioids (p < 0.001). Oxycodone immediate release was the most frequently prescribed analgesic. Logistic regression modelling controlling for patient and disease characteristics significantly predicted more non-opioid (p < 0.001) and alpha-blocker (p = 0.037) prescription with clinician training < 3 years. Linear regression modelling demonstrated that clinicians training < 3 years predicted lower OMEs per prescription compared to clinicians with ≥ 3 years of training (p = 0.001). Subgroup analyses supported similar predictions with training.

CONCLUSIONS

Prescribing patterns are associated with different clinician experience levels. However, a substantial amount of opioids are still given overall on patient discharge regardless of the clinician experience. Educational interventions aimed at reducing the opioid prescription rate and quantities may be considered for clinicians of all training levels.

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

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.

Inappropriate opioid prescription after surgery

Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy efforts to reduce such prescribing while ensuring adequate pain control.

Low-dose intravenous ketamine versus intravenous ketorolac in pain control in patients with acute renal colic in an emergency setting: a double-blind randomized clinical trial

BACKGROUND

This study was conducted to compare the effectiveness of low-dose ketamine versus ketorolac in pain control in patients with acute renal colic presenting to the emergency department (ED).

METHODS

This is a double-blind randomized clinical trial. The initial pain severity was assessed using the numerical rating scale (NRS). Then, ketamine or ketorolac was administered intravenously at a dose of 0.6 mg/kg and 30 mg respectively. The pain severity and adverse drug reactions were recorded 5, 15, 30, 60, and 120 min thereafter.

RESULTS

The data of 62 subjects in the ketamine group and 64 patients in the ketorolac group were analyzed. The mean age of the patients was 34.2 ± 9.9 and 37.9 ± 10.6 years in the ketamine and ketorolac group, respectively. There was no significant difference in the mean NRS scores at each time point, except for the 5 min, between the two groups. Despite a marked decrease in pain severity in the ketamine group from drug administration at the 5 min, a slight increase in pain was observed from the 5 min to the 15 min. The rate of adverse drug reactions, including dizziness (P = 0.001), agitation (P = 0.002), increased systolic blood pressure (> 140 mmHg), and diastolic blood pressure (> 90 mmHg) was higher in the ketamine group.

CONCLUSIONS

Low dose ketamine is as effective as ketorolac in pain management in patients with renal colic presenting to the ED. However, it is associated with a higher rate of adverse drug reactions.

Évaluation de l'intérêt d'une consultation post-urgence d'urologie : étude rétrospective sur trois ans

Introduction : L'objectif principal de ce travail était d'évaluer l'intérêt de la consultation post-urgence d'urologie (CPUU) mise en place dans notre institution.

Patients et méthodes : Il s'agit d'une étude transversale, monocentrique et rétrospective sur trois années distinctes : 2014, 2015 et 2016 de trois mois consécutifs (janvier à mars). Seuls les patients de plus de 18 ans ayant consulté aux urgences pour un motif urologique et relevant de la CPUU ont été inclus.

Résultats : Au total, 465 patients ont été programmés en CPUU, dont 265 (57 %) se sont présentés à la consultation. Deux cent vingt-deux patients (48 %) ont finalement répondu aux critères d'inclusion. Les principaux diagnostics relevant de la CPUU étaient principalement les coliques néphrétiques (45 %), la rétention aiguë d'urine (14 %) et les infections de l'appareil urinaire (16 %). On note une diminution significative du délai de CPUU passant à moins de deux semaines pour 60 % des patients en 2016 contre 30 et 38 % respectivement en 2014 et 2015 (p = 0,003). Le nombre de modifications diagnostiques à la sortie de la CPUU reste faible (6 % sur les trois ans ; p = 0,94). La modification thérapeutique par les urologues était principalement chirurgicale (22 % ; p = 0,75). La CPUU a permis d'instaurer un suivi au long cours pour plus de la moitié des patients (60 % ; p = 0,31).

Conclusion : La CPUU semble démontrer un intérêt tant sur le plan diagnostique que sur le plan du suivi spécialisé dans notre centre.

What is the best analgesic option for patients presenting with renal colic to the emergency department? Protocol for a systematic review and meta-analysis

INTRODUCTION

Patients with renal colic present to the emergency department in excruciating pain. There is variability in practice regarding the choice of initial analgesic to be used in renal colic. The aim of this article is to outline the protocol for review of the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs), opioids and paracetamol use in renal colic pain management.

METHODS AND ANALYSIS

This is the protocol for a systematic review, comparing efficacy of NSAIDs, opioids and paracetamol in renal colic studied under randomised controlled trial (RCT) design. This protocol reporting is based on the PRISMA-P recommendations (PRISMA-P-checklist). We will conduct a comprehensive literature search for both peer-reviewed and grey literature published until 18 December 2016. Using a predefined search strategy, MEDLINE, Embase and Cochrane Central Register of Controlled Trials will be searched. Additional searches will include WHO International Clinical Trials Registry Platform, abstract list of relevant major conferences and the reference lists of relevant publications. Two authors will independently screen and identify the studies to be included. The RCT comparing NSAIDs versus opioids or paracetamol will be included in the review, if the age of participants in the study was >16 years and they presented with moderate to severe renal colic. Any disagreement between the screening authors will be resolved through discussion and reaching consensus; if not, a third reviewer will arbitrate. Quantitative data from homogeneous studies will be pooled in the meta-analysis using RevMan V.5.3 software. The findings of this review will be presented according to the guidelines in the Cochrane Handbook of Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Review and Meta-Analysis statement.

ETHICS AND DISSEMINATION

Formal ethics approval is not required, as primary data will not be collected. We plan to publish the result of this review in a peer-reviewed journal.