Non-opioid pain management pathways for stone disease.

New opioid dependency following urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures due to recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing following urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Two literature searches were performed using PubMed. Firstly, we searched available literature concerning opioid-sparing pathways in acute renal colic. Secondly, we searched available literature for opioid-sparing pathways in ureteroscopy and PCNL. Abstracts were reviewed for inclusion in our narrative review. In the setting of acute renal colic, multiple randomized control trials have shown that NSAIDs attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison to opioids. NSAIDs also form a core component in management of post-ureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared to opioids. Multiple opioid-free pathways have been described for post-ureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols following percutaneous nephrolithotomy are less well described but have yielded a reduction in post-operative opioid requirements. In select patients, both acute renal colic and following kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to post-operative pain outcomes limited due to lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multi-modal post-surgical pain management pathways.