Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Squamous cell carcinoma of the right renal pelvis in a 46-years-old with long history of right pyelolithiasis. A case report and review of literature

Squamous cell carcinoma of the kidney is a rare malignancy of the upper urothelium usually seen at advanced stage due to delay in diagnosis and or presentation. Mostly seen in patients with history of untreated chronic urolithiasis, chronic renal infection or analgesic abuse. A 46-years-old man who presented with right recurrent loin pain that radiates to the right groin of 10 years duration which worsened 2 weeks prior to presentation, he had history of recent haematuria, right loin pain, significant weight lost with associated history of untreated right renal calculi. General examination was not remarkable, ultrasound scan revealed a huge right renal mass with calculi. Intravenous urogram showed a non-functioning right kidney. Right radical nephrectomy was done, cut surface showed replacement of the renal parenchyma with greyish white tumour with stones in some blind calyxes. Histology revealed moderately differentiated squamous cell carcinoma of the right kidney. We report a case of moderately differentiated squamous cell carcinoma of the right kidney in a patient with a long history of untreated renal calculi. High index of suspicion for malignancy should be kept when seeing patients with long history of untreated renal calculi.</jats:p