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SAN FRANCISCO -- Non-narcotic management of kidney stone pain in the emergency department (ED) led to earlier discharge and fewer hospital admissions as compared with initial opioid management, data from a leading stone center showed.

Patients treated only with ketorolac were almost twice as likely to be discharged from the ED in less than 3 hours versus patients who received only opioids. Patients who received narcotics only or a combination of opioids and ketorolac were two to four times more likely to be admitted to the hospital.

"We have a million ED visits annually for stones; we know that stone patients are at extremely high risk for developing opioid dependence ... we know that 80% of the patients have been treated with opioids, and we've known for 25 years that that's the wrong drug. We wanted to do something about it," Andrew Portis, MD, of HealthEast Kidney Stone Institute in Minneapolis, said during a press briefing at the American Urological Association (AUA) meeting.

"The formation of a kidney stone does not immediately cause pain. Even when a stone drops from the kidney into the ureter, a patient may remain asymptomatic," said Portis. "The pain arises only when ureteral smooth muscle contracts around the stone, causing a spasm."

Opioid medications can mask the pain, he continued, but non-steroidal antiinflammatory drugs (NSAIDs) actually break the spasm. Ketorolac is preferred because it is available in an intravenous formulation.

"This is a more effective approach, and we've known this for 25 years," he reiterated.

Relieving the pain has direct implications for stone passage without surgical intervention. As reported , patients with a pain score ≥6 by the NIH-backed index were seven times less likely to attempt stone passage, and almost three times more likely to fail an attempt to pass a stone.

Portis' group developed a as part of efforts to improve nonsurgical management of painful kidney stones (renal colic) in the ED. The protocol emphasizes non-narcotic management.

Following implementation of the protocol, the proportion of patients with a PROMIS score ≥6 decreased significantly (P=0.002), attempts at stone passage increased (P=0.006), and the number of stone surgeries declined (P=0.01). Experience with the protocol also showed that a considerable amount of time was devoted to persuading patients and clinicians to accept non-narcotic pain relief.

As part of the implementation of the transition-of-care protocol, Portis' group evaluated different strategies for relieving renal colic in the ED. They retrospectively examined characteristics, patterns of treatment, and outcomes of patients treated in the ED at a major metropolitan health center.

Inclusion criteria consisted of age ≥18; ureteral stones 2-10 mm confirmed by CT; initial PROMIS score >6; and initial treatment with ketorolac only, narcotic medication only, or both ketorolac and a narcotic administered within a 10-minute interval. Patients with an ED visit within the past 120 days were excluded.

Data analysis included 1,335 patients. The results showed that 29% of the patients received ketorolac alone, 40% received only a narcotic, and 32% received the combination. About a third of the ketorolac group received narcotic rescue medication, as compared with about half of the other two groups.

Patients started on narcotics alone were older (51 vs 46-47 for the other two groups), and both narcotic groups had slightly higher initial pain scores (8.6, 8.9 vs 8.3). Stone size and location did not differ significantly among the groups. Time to pain score <5 ranged between 1.8 and 2.5 hours, lowest in the combination group, highest in the opioid group.

Patients started on opioid medication alone had the longest stay in the ED (4.0 vs 3.4 hours for the other two groups, P<0.001) and were significantly less likely to be discharged from the ED (83.4% vs 92.4% for the combination, 96.1% for ketorolac alone, P<0.001).

The odds ratio for discharge within 3 hours was 1.9 for ketorolac versus narcotic-only (95% CI 1.3-2.8, P<0.001) and 1.6 for the combination group versus narcotic only (95% CI 1.1-2.3, P<0.009). The OR for hospital admission was 4.0 for patients treated with narcotics alone versus ketorolac (95% CI 2.2-7.2, P<0.001) and 2.1 for the combination versus ketorolac (95% CI 1.1-4.0, P=0.028).

"The addition of the narcotic to ketorolac really didn't do anything, with the exception that the patients were more likely to get admitted to hospital, which was usually because of nausea, which was associated with the narcotic," said Portis. The data showed that ketorolac alone as the initial strategy was associated with significantly less use of antiemetic drugs than either of the other two strategies (P<0.001).

"An added benefit of the ketorolac-only strategy is that patients avoid problems with opioid-induced constipation," he added.

AUA press briefing moderator Ben Davies, MD, of the University of Pittsburgh Medical Center, said the study "informs steps that we can take to revisit how we prescribe opioid medications without compromising the quality of patient care that we provide."

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