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Objective: To analyze the National Hospital Ambulatory Medical Care Survey (NHAMCS) database to determine geographic and temporal trends, as well as variables associated with the likelihood of receiving an opioid prescription for urolithiasis in United States (US) emergency departments (EDs).Materials and Methods: All ED visits for urolithiasis between 2006 and 2018 in the NHAMCS database were analyzed. Age, race/ethnicity, insurance status, ED provider credentials, geographic region, and urban vs rural hospital status were extracted. Linear regression was used to examine overall/regional trends in opioid prescriptions over time. Logistic regression was used to estimate factors associated with higher odds of receiving opioids.Results: Fourteen million visits were analyzed, of which, 79.1% (11.0 million) received an opioid prescription. From 2014 to 2018 there was a decline of 3.65%/year of the proportion of visits receiving an opioid prescription (R2 = 0.86, P = .008). Non-Hispanic Black race was associated with a lower chance of receiving opioid prescription (OR = 0.57, P = .02) compared to Non-Hispanic Whites (NHW). Midwestern hospitals had higher odds of opioid prescription compared to the Northeast (OR = 2.05, P = .006). Rural hospitals had lower odds of opioid prescription compared to urban hospitals (OR = 0.62, P = .02).Conclusion: Opioid prescriptions for patients presenting with urolithiasis to the ED have steadily declined from 2014 to 2018, except in the Midwest. NHW race, Midwest region, and urban EDs increase the likelihood of receiving opioids. Continued efforts encouraging non-opioid alternatives for urolithiasis are essential, specifically in Midwestern EDs, to mitigate the ongoing opioid epidemic in the US. [ABSTRACT FROM AUTHOR]