Kidney stone pain overtreated in ER but lighter approach just as effective, data say

When kidney stone patients come into emergency rooms, complaining that the pain is worse than childbirth, or falling off a roof, doctors often have been persuaded to overtreat them with potent opioid painkillers.

"I better use the big gun" is what many doctors think, said Dr. Andrew Portis, director of the HealthEast Kidney Stone Institute in St. Paul.

Trouble is, new data suggest that another common medication works equally well, and that prescriptions of opioids create problems ranging from nausea to addiction for these patients.

HealthEast examined outcomes of kidney stone patients at its three east metro ERs over three years, and generally found better results when patients were given Toradol anti-inflammatory drugs instead of opioids.

Fewer Toradol patients needed additional medications, such as anti-nausea drugs, or admissions to the hospitals, according to results that Portis presented Friday to the American Urological Association's annual meeting in San Francisco. Toradol patients had shorter ER stays as well.

"Our tradition is big pain deserves big medications," Portis said. "More and more, we're learning that the little medications, when targeted appropriately, are actually more effective."

HealthEast has even seen a decline in surgical procedures to remove kidney stones — 75 percent of patients now try to pass stones on their own compared to 60 percent three years ago — because the non-opioid medications relieve their pain more effectively, Portis said.

Toradol works as a pain reliever, and also relaxes the muscles spasms that trap kidney stones as they try to exit the kidneys and bladder.

The rush to prescribe opioids in kidney stone care has been part of what is now being termed as a national epidemic of opioid painkiller overuse and misuse. Deaths from overdoses of prescription and illicit opioids have increased sixfold in Minnesota over the past two decades.

The problem has been somewhat unique in kidney stone care, because stones cause such excruciating pain.

The prospect theory of decisionmaking says that people in desperation make urgent decisions without concern for long-term consequences. Portis said that probably explains why patients demand opioids to relieve kidney stone pain. Doctors get emotionally caught up in their patients' needs as well.

Portis said he hopes these findings will encourage changes in how doctors practice and prescribe medications. The level of pain is actually a bad indicator of the size and severity of a stone, he noted.

"Stone patients go, 'this one has to be a bad one. It really hurts!' " Portis said. "From our experience, it's the little ones that hurt more than the large ones."

Jeremy Olson • 612-673-7744