Discharge opioid preferences

[enalli]

The two pain medicine threads on the front page got me thinking about our opioid prescribing patterns.

Do any of you have specific medication preferences when prescribing outpatient opioids? If so, do you have a particular reason for choosing that drug?

Of course, this is all assuming a low-dose, short-term course for appropriate diagnoses in conjunction with non-opioid analgesics.

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[Rekt]

The two pain medicine threads on the front page got me thinking about our opioid prescribing patterns.

Do any of you have specific medication preferences when prescribing outpatient opioids? If so, do you have a particular reason for choosing that drug?

Of course, this is all assuming a low-dose, short-term course for appropriate diagnoses in conjunction with non-opioid analgesics.

What are you writing it for? I rarely write any. If I do it's usually hydrocodone 5/325s for 3-4 days max. Enough to see PCP. I'm nicer to people with fractures, but that's about it.

 

[enalli]

What are you writing it for? I rarely write any. If I do it's usually hydrocodone 5/325s for 3-4 days max. Enough to see PCP. I'm nicer to people with fractures, but that's about it.

Mainly fractures as well.

Any reason you prefer Vicodin over some of the other options?

 

[Groove]

The two pain medicine threads on the front page got me thinking about our opioid prescribing patterns.

Do any of you have specific medication preferences when prescribing outpatient opioids? If so, do you have a particular reason for choosing that drug?

Of course, this is all assuming a low-dose, short-term course for appropriate diagnoses in conjunction with non-opioid analgesics.

I rarely write them. I'll assume that when you do, as do I, it's for a valid diagnosis and within a reasonable clinical context (You seemed to say as much). In which case, I can't write more then 3 days without significant oversight per state regulations and will get calls from the pharmacy requesting ICD 10 codes, etc.. So, in those select few cases, I'll typically only write for Tylenol #3, Tramadol and/or Norco depending on the dx. I probably write them more for fractures, really bad corneal abrasions and recent post op patients from one of our surgeons than anything else. I also sometimes write them for kidney stone patients that I've had difficulty with appropriate analgesia during the ED course though I'll admit their use isn't en vogue with current EBM approaches. However, I've noticed I get far fewer bounce back kidney stones to the ED for pain control which might end up requiring a call to urology 50% of the time depending on what's going on...and I just hate calling urology. Our local urologists are all major di*ks...PUN intended. For the vast majority of my pt's, I write non opioid/narcotic Rx.

 

[Rekt]

Mainly fractures as well.

Any reason you prefer Vicodin over some of the other options?

I grew up with the mindset of opioids being bad. Similar to how the view point of smoking changed over time. All this nonsense in the news over the past few years wasn't surprising to me in the least. Growing up Vicodin, now I guess mainly called Norco, was the joke opioid. Everyone wanted Percocets because the high was better. I really just use it assuming the euphoria is less. That's about it.

I don't think there's really much pattern/EBM for specific therapies for actual narcotics and doses and everyone just does whatever they learned or what feels right. (In regards to opiates specifically, lots of great EBM/practices on non opiate therapy).

 

[bravotwozero]

Dolobid. Say it really fast in front of the patient, so they think they're getting dilaudid.

 

[deleted245139]

We have dolobid on formulary. I'm a fan

 

[RoyBasch]

I like IR morphine, very un-euphoric. Drug seekers hate it. Try very hard to avoid oxycodone containing prescriptions. I probably prescribe percocet only once every 2-3 months. Almost never prescribe tramadol ("The prison wine of opiates"). Tramadol is less effective than hydrocodone and morphine without a better safety profile. Have seen a significant number of seizures in patients recently Rx'd tramadol. All the super big gun stuff: duragesic, opana, MS contin, oxycontin are an absolute never. And I say they're are very few "nevers" in emergency medicine.

 

[bravotwozero]

On a more serious note, Norco 5/10 3-5 day supply for kidney stones or fractures. In my experience, if i discharge a kidney stone patient with anything besides a norco, they almost always bounce back for inadequate pain control. Traumas/sprain/radiculopathy usually get either a tylenol 3 or naproxen/robaxin combo.

 

[Tenk]

 

[enalli]

I like IR morphine, very un-euphoric. Drug seekers hate it. Try very hard to avoid oxycodone containing prescriptions. I probably prescribe percocet only once every 2-3 months. Almost never prescribe tramadol ("The prison wine of opiates"). Tramadol is less effective than hydrocodone and morphine without a better safety profile. Have seen a significant number of seizures in patients recently Rx'd tramadol. All the super big gun stuff: duragesic, opana, MS contin, oxycontin are an absolute never. And I say they're are very few "nevers" in emergency medicine.

I have read this about IR morphine several times, but it seems like very few people prescribe it. Any ideas why it's not more widely used (when compared to hydrocodone/codeine/oxycodone)?

 

[thegenius]

The two pain medicine threads on the front page got me thinking about our opioid prescribing patterns.

Do any of you have specific medication preferences when prescribing outpatient opioids? If so, do you have a particular reason for choosing that drug?

Of course, this is all assuming a low-dose, short-term course for appropriate diagnoses in conjunction with non-opioid analgesics.

LOL

Default for me is Norco 5-325 1 tab PO QID, dispense 12 (3 days)

I modify it every now and then.

Edit: I'm probably gonna change my default to Norco 5-325, 1 tab PO BID, dispense 6 (or 8). Not like it's gonna matter, they will just come right on back to the ED, not pay a co-pay, generate a $2500 bill and not see a dime of that, and demand more. WTF kind of society do we live in? It's ridiculous!

 

[thegenius]

I rarely write them. I'll assume that when you do, as do I, it's for a valid diagnosis and within a reasonable clinical context (You seemed to say as much). In which case, I can't write more then 3 days without significant oversight per state regulations and will get calls from the pharmacy requesting ICD 10 codes, etc.. So, in those select few cases, I'll typically only write for Tylenol #3, Tramadol and/or Norco depending on the dx. I probably write them more for fractures, really bad corneal abrasions and recent post op patients from one of our surgeons than anything else. I also sometimes write them for kidney stone patients that I've had difficulty with appropriate analgesia during the ED course though I'll admit their use isn't en vogue with current EBM approaches. However, I've noticed I get far fewer bounce back kidney stones to the ED for pain control which might end up requiring a call to urology 50% of the time depending on what's going on...and I just hate calling urology. Our local urologists are all major di*ks...PUN intended. For the vast majority of my pt's, I write non opioid/narcotic Rx.

Remember R52. That's the ICD 10 code for "pain". I don't think it's right for pharmacies to know the patient's diagnosis. So every single script I write for is "ICD-10: R52"

I know there is evidence that NSAIDs are just as good as opiates for kidney stone pain. In general I call bullocks. Those studies should be performed in an inner city, low-socioeconomic ER population that is addicted to opiates. Then they will realize that narcotics are better than NSAIDs.

I mean...you come to the ER in severe pain. I've never had a kidney stone but from what I've seen, I never want one. Seems absolutely horrible! So you come to the ER with like "what the F is this pain I'm feeling, did I pull a muscle or something? I've taken tylenol and motrin and I feel like I'm going to die" and you are gonna explain to them that EBM says NSAIDs is the best treatment? Yes you gotta judge these people and if you've given them toradol 15 IV, Ofirmev IV, and even bothering with lidocaine IV, then you'll gonna give them dilaudid 1 or morphine 8 to calm them down. Those patients might need narcs on discharge.

(The second part is not a rant against you Groove)

 

[thegenius]

Dolobid. Say it really fast in front of the patient, so they think they're getting dilaudid.

Dolobid is expensive!
https://www.goodrx.com/dolobid

 

[RustedFox]

Here in Florida, "House Bill 21" states that I cannot write for more than 3 days worth of opioid without documenting a damn good reason, and it encourages me to also prescribe Narcan.

3 days of percocet is okay with me for the vast majority of "legit" complaints. (Fractures, stones, etc).

My most recent "customer complaint" actually reads: "I wanted percocets (sic) for my husband."
MVC. No injury. Man the hell up.
I have been in three gnarly MVCs. I was sore for days. I never wanted an opioid.

 

[deleted109597]

I haven't prescribed percocet since I left NC 8 years ago.
Texas required special prescription pads that I didn't purchase up until 2 years ago when they changed Norco to schedule 2.
In 2 years I have probably written 10 schedule 2 prescriptions.
Texas is amazing when it comes to not having drug seekers. I'm not kidding. I've worked in multiple hospitals in multiple cities and you don't have people scamming to get percocets because they know they simply won't get them.

 

[SamtheWise]

I usually do a few days of those buccal fentanyl lollipops, pain in the butt to Rx though, you gotta call around to all the 24 hour walgreens and see who even has 150 of them in stock

 

[WilcoWorld]

I know there is evidence that NSAIDs are just as good as opiates for kidney stone pain. In general I call bullocks.

You're right that NSAIDs aren't just as good as opioids for renal colic - THEY'RE BETTER

I've taken tylenol and motrin and I feel like I'm going to die

I feel like they never say the motrin part. It's more like, "I've taken tylenol, I even took one of my wife's Vicodin, and the nurse gave me dilaudid and I still wish I was dead." 15 mg of toradol and 10 minutes later the patient thinks I'm the best doctor in the world.
(I know, I know, I could give PO ibuprofen, but part of medicine is theater, and needles make great theater).
That all said, I don't begrudge your writing a short script for a kidney stone patient. I'll give an Rx for 6 or so as a security blanket, "Take 3 ibuprofen for pain. If it isn't much better in an hour, you can take a vicodin. If you need to do that more than six times, I'm worried things got worse & I want you to come back to the ER or get into see your doctor."

And on another not-very related note, I believe it's spelled "bollocks", but I learned that from The Sex Pistols.
I am confident you can spell "begonias" with no problem

 

[WilcoWorld]

I have read this about IR morphine several times, but it seems like very few people prescribe it. Any ideas why it's not more widely used (when compared to hydrocodone/codeine/oxycodone)?

In palliative care IR morphine is widely used. There is rarely a good reason to select hydro/oxy, there are frequently good reasons not to use codeine, and there's almost always a good reason not to prescribe tramadol.

Palliative pharmacists have an opioid mantra, "why not morphine?".

It's less euphorogenic, it's cheap, it's available in a lot of formulations. True morphine allergy is quite rare, and such patients should only get synthetyic opioids, so oxy/hydro/dilaudid/codeine are all out too in the case of allergy.

Since I started studying pain treatment, morphine is my go to oral opioid. If the patient doesn't have renal failure, you should probably make it your opioid of choice too.

 

[WilcoWorld]

I like IR morphine, very un-euphoric. Drug seekers hate it. Try very hard to avoid oxycodone containing prescriptions. I probably prescribe percocet only once every 2-3 months. Almost never prescribe tramadol ("The prison wine of opiates"). Tramadol is less effective than hydrocodone and morphine without a better safety profile. Have seen a significant number of seizures in patients recently Rx'd tramadol. All the super big gun stuff: duragesic, opana, MS contin, oxycontin are an absolute never. And I say they're are very few "nevers" in emergency medicine.

Agree, except MS Contin is a good drug. However, it's for chronic cancer pain, almost no ED indication for it.

 

[WilcoWorld]

Another thing I like about morphine (that perhaps doesn't play well to PG scores, but whatever) is that most patients act like "whoah! morphine?"

I think it helps them realize that this is a highly addictive, potentially fatal medicine they're taking, and they should take it seriously. "Vicodin" "Percocet" "Norco" etc. all allow them to fool themselves a little bit.

 

[thegenius]

I usually do a few days of those buccal fentanyl lollipops, pain in the butt to Rx though, you gotta call around to all the 24 hour walgreens and see who even has 150 of them in stock

Whoa. I've never even heard of that
buccal fentanyl
Hmmm

 

[thegenius]

You're right that NSAIDs aren't just as good as opioids for renal colic - THEY'RE BETTER



I feel like they never say the motrin part. It's more like, "I've taken tylenol, I even took one of my wife's Vicodin, and the nurse gave me dilaudid and I still wish I was dead." 15 mg of toradol and 10 minutes later the patient thinks I'm the best doctor in the world.
(I know, I know, I could give PO ibuprofen, but part of medicine is theater, and needles make great theater).
That all said, I don't begrudge your writing a short script for a kidney stone patient. I'll give an Rx for 6 or so as a security blanket, "Take 3 ibuprofen for pain. If it isn't much better in an hour, you can take a vicodin. If you need to do that more than six times, I'm worried things got worse & I want you to come back to the ER or get into see your doctor."

And on another not-very related note, I believe it's spelled "bollocks", but I learned that from The Sex Pistols.
I am confident you can spell "begonias" with no problem

Yup yup...spelled bollocks wrong.
agree with the above, although I tell them NOT to come back to the ER. I try to tell almost all people not to come back to the ER.
I hate it when people come back to the ER. If they come back, then you give them morphine or "Vit D"
I guess you could admit them, but I don't like admitting renal colic unless you have an infection or your Cr is getting much worse.

 

[WilcoWorld]

Yup yup...spelled bollocks wrong.
agree with the above, although I tell them NOT to come back to the ER. I try to tell almost all people not to come back to the ER.
I hate it when people come back to the ER. If they come back, then you give them morphine or "Vit D"
I guess you could admit them, but I don't like admitting renal colic unless you have an infection or your Cr is getting much worse.

yeah, I don't internet well.

 

[enalli]

In palliative care IR morphine is widely used. There is rarely a good reason to select hydro/oxy, there are frequently good reasons not to use codeine, and there's almost always a good reason not to prescribe tramadol.

Palliative pharmacists have an opioid mantra, "why not morphine?".

It's less euphorogenic, it's cheap, it's available in a lot of formulations. True morphine allergy is quite rare, and such patients should only get synthetyic opioids, so oxy/hydro/dilaudid/codeine are all out too in the case of allergy.

Since I started studying pain treatment, morphine is my go to oral opioid. If the patient doesn't have renal failure, you should probably make it your opioid of choice too.

The main reason why I don't use it is that (as far as I know) the lowest-dose IR tab is 15 mg. I believe that translates to 10 mg of oxy and 10-15 mg of hydrocodone. In an opioid-naive patient, I like to prescribe a lower dose than that.

For your opioid-naive patients, do you usually prescribe Morphine IR at 15 mg, do you tell them to break the tablet in half, or is there a lower-dose tablet that makes all this moot?

 

[WilcoWorld]

Oral/IV morphine is a 3/1 conversion, so 15 of PO morphine is about 5 IV and a half a tab PO is about 2.5 IV.
In 70 kg adults having severe pain I think those are safe doses, and I'm comfortable prescribing them. I should clarify that I wouldn't prescribe PO morphine to someone who didn't have a clear diagnosis consistent with severe pain.

Of course that isn't all of your patients. There's often a good reply to the question, "why not morphine?"

 

[RoyBasch]

The main reason why I don't use it is that (as far as I know) the lowest-dose IR tab is 15 mg. I believe that translates to 10 mg of oxy and 10-15 mg of hydrocodone. In an opioid-naive patient, I like to prescribe a lower dose than that.

For your opioid-naive patients, do you usually prescribe Morphine IR at 15 mg, do you tell them to break the tablet in half, or is there a lower-dose tablet that makes all this moot?

You are correct 15mg I think is the smallest dose of IR morphine.

However, perhaps the palliative care people can back me up on this, but the bioavailability of morphine PO is quite different than IV. Morphine is subject to significant first mass metabolism so the conversion rate of IR PO to IV is about 3:1. So 15 mg of PO IR morphine is roughly equivalent to 5mg of IV morphine. Which is a pretty standard dose for the average opiate naive adult.

15mg of PO IR morphine is roughly equi-analgesic with 5mg hydrocodone and and actually less analgesic that a similar dose of oxycodone (probably equal to only about 3mg of oxycodone).

 

[deleted836128]

Damn... this thread has got me thinking. In my ER we have a lot of more experienced docs and some older docs and there are A LOT of narcotic prescriptions written. One doc, who I know and love, gives out tramadol prescriptions like candy. Many of our docs and PAs write prescriptions for narcotics for any pain without even thinking, usually no more than five days at a time... but I’ve seen a shift in some of the greener providers (including myself) towards writing less narcotics. I used to write about 35 narcotic prescriptions per month and now much less. Often a whole shift goes by without writing any. I can count the number of kids I’ve prescribed narcotics to (less than ten). I often do write them for fractures in adults. Almost always for kidney stone pain because it’s horrific. I know ibuprofen works better but if they need something for breakthrough pain then I would rather write it than have them bounce back in the ER. Sometimes I will write for severe dental pain. I never write narcotics for chronic pain, belly pain of unknown cause, strains and sprains. When I do write them the patient usually gets no more than a three day supply. I try to avoid tramadol (a nasty medication) and usually opt for hydrocodone or oxycodone. For non-narcotics I adore Robaxin, lidocaine patches and DICLOFENAC! The gel or tablets, incredible - people think they’re getting something life changing.

 

[bravotwozero]

You're right that NSAIDs aren't just as good as opioids for renal colic - THEY'RE BETTER



I feel like they never say the motrin part. It's more like, "I've taken tylenol, I even took one of my wife's Vicodin, and the nurse gave me dilaudid and I still wish I was dead." 15 mg of toradol and 10 minutes later the patient thinks I'm the best doctor in the world.

Can't say this has been my experience. Haven't fixed a single renal colic with toradol alone. Plus in that 10 minutes, they will be writhing around doing the kidney stone dance. I've had females with renal colic tell me the pain was worse than going into labor. That sounds quite miserable, and I can't see how toradol alone would make that disappear.

 

[deleted497653]

Can't say this has been my experience. Haven't fixed a single renal colic with toradol alone. Plus in that 10 minutes, they will be writhing around doing the kidney stone dance. I've had females with renal colic tell me the pain was worse than going into labor. That sounds quite miserable, and I can't see how toradol alone would make that disappear.

Me too. I feel bad for kidney stone pain.

However, can someone do a study for why people with kidney stones still in the kidney have pain. Theoretically they shouldn’t have pain unless there is a stone on the way out or just recently passed.

 

[RoyBasch]

Damn... this thread has got me thinking. In my ER we have a lot of more experienced docs and some older docs and there are A LOT of narcotic prescriptions written.

The attitude towards opiates has shifted fairly rapidly in just a few years. The idea that opiates are "bad" is kind of new. 20 years ago they were saying oxycodone is great because it's not addictive. The pain score was invented and the goal was for everyone to be a "0." We now appreciate that most of these were scams created by the manufacturers like Purdue to sell more opiates and they were based on bad studies and opinions quoted as studies.

I am on the younger side and even when I was in medical school only a decade ago they were teaching us that "pain is under treated and under medicated." It seems to be only in the last 2-3 years the idea that there is an "opiate epidemic" and decreased prescribing came in to vogue. That's why I think some of the older docs still prescribe a lot. It's what they were taught. That being said, I would hope people keep up with changing practices and ideas and don't keep practicing perfect 1998 medicine.

 

[WilcoWorld]

Can't say this has been my experience. Haven't fixed a single renal colic with toradol alone. Plus in that 10 minutes, they will be writhing around doing the kidney stone dance. I've had females with renal colic tell me the pain was worse than going into labor. That sounds quite miserable, and I can't see how toradol alone would make that disappear.

I fear that in my eagerness to make a funny music reference (bollocks & begonias) I have been less than clear about my medical point.

I don't mean to say people should exclusively use NSAIDs for renal colic. I find that NSAIDs work best, but I don't use them as monotherapy.

My typical 1st set of orders for presumed renal colic:
15 mg toradol IV
0.1 mg/kg of morphine IV
antiemetic dujour
Urinalysis

 

[WilcoWorld]

Me too. I feel bad for kidney stone pain.

However, can someone do a study for why people with kidney stones still in the kidney have pain. Theoretically they shouldn’t have pain unless there is a stone on the way out or just recently passed.

I have always assumed that those were red herrings and that the pain was from a different cause.

 

[GonnaBeADoc2222]

Can't say this has been my experience. Haven't fixed a single renal colic with toradol alone. Plus in that 10 minutes, they will be writhing around doing the kidney stone dance. I've had females with renal colic tell me the pain was worse than going into labor. That sounds quite miserable, and I can't see how toradol alone would make that disappear.

I've completely relieved renal colic pain with just toradol after the patient themself declined opiates.

Sent from my Pixel 3 using SDN mobile

 

[killerleaf]

My daughter did say that it was easier to birth the two grandbabies than her two kidney stones. The first stone, she was refusing all opiods, but at about hour 12 she did finally accept something. no, I don't remember what it was--it was 18 years ago. (probably hydrocodone) The second time, when they offered pain meds, she took them up on the offer right away, but she says it was still agonizing. However, when she was discharged, she was only sent home with 2 days worth of prescriptions, with no refills. She did just fine with that...it knocked the pain down to where just tylenol could handle it.

 

[pkwraith]

If someone needs opioid therapy, I will do 5 mg oxycodone. Instructions includes max therapy scheduled ibuprofen and tylenol, and then the oxycodone only for breakthough. It's much easier to teach and for the patient to remember.
I dislike the combination APAP products, due to the overdose potential of the tylenol, and a lot harder to teach them the appropriate safe regimen. If hydrocodone came as monotherapy, I'd use it a lot more in conjunction with scheduled non-opioid regimen. I use the occasional norco when its so few doses that APAP overdose is unlikely.

Tramadol and Tylenol 3 I rarely use. If someone actually needs opioids, I'd rather give them something effective, without the side effects of codeine and tramadol, unless they are one of the few % responders and they usually know themselves.

Would use morphine IR a lot more, but more people seem to report more "adverse" reactions with it, whether imagined or not, I assume from the higher histaimne release.

Rx for 3 days or less. No simultaneous benzos. No extended release. No dilaudid or anything over 5 mg oxycodone.

Exceptions to above for cancer and hospice (true DNR kind).

 

[Fox800]

If someone needs opioid therapy, I will do 5 mg oxycodone. Instructions includes max therapy scheduled ibuprofen and tylenol, and then the oxycodone only for breakthough. It's much easier to teach and for the patient to remember.
I dislike the combination APAP products, due to the overdose potential of the tylenol, and a lot harder to teach them the appropriate safe regimen. If hydrocodone came as monotherapy, I'd use it a lot more in conjunction with scheduled non-opioid regimen. I use the occasional norco when its so few doses that APAP overdose is unlikely.

Tramadol and Tylenol 3 I rarely use. If someone actually needs opioids, I'd rather give them something effective, without the side effects of codeine and tramadol, unless they are one of the few % responders and they usually know themselves.

Would use morphine IR a lot more, but more people seem to report more "adverse" reactions with it, whether imagined or not, I assume from the higher histaimne release.

Rx for 3 days or less. No simultaneous benzos. No extended release. No dilaudid or anything over 5 mg oxycodone.

Exceptions to above for cancer and hospice (true DNR kind).

You and I are very similar. I do APAP 1g q8h, ibuprofen 400 mg q6h, oxycodone 5-10 mg (5mg tablets) q6h PRN for severe pain.

Qty 12-15 oxys, but less than that if they just seem to have low ninja titers and I'm doing it to get them out the door (qty 5-8).

I may give 10 mg oxy tablets instead if they have a legitimate long bone fracture or extenuating circumstances and seem miserable.

 

[Whatyousay]

The main reason why I don't use it is that (as far as I know) the lowest-dose IR tab is 15 mg. I believe that translates to 10 mg of oxy and 10-15 mg of hydrocodone. In an opioid-naive patient, I like to prescribe a lower dose than that.

For your opioid-naive patients, do you usually prescribe Morphine IR at 15 mg, do you tell them to break the tablet in half, or is there a lower-dose tablet that makes all this moot?

Morphine IR tabs can be split. In my normal practice for an opiate naive patient in clinic I'll prescribe morphine IR 15mg q4hr w/ instructions to take 1/2 tab for breakthrough pain. Will write for oxycodone only in patients with renal dysfunction.

There are liquid formulations of morphine that can provide a little more flexibility in dosing regimen, although their use is generally limited to oncology or hospice patients.

Hospice/palliative literature suggests that PO morphine has roughly the same analgesic properties as hydrocodone (1:1 ratio), while oxycodone is slightly stronger (1:1.25 ratio). The caveat to all of this is that the evidence comparing the relative analgesic properties of various opiates is all pretty subjective ... we're literally giving people meds and asking them to rate their improvement in pain.

In theory: 15mg PO morphine ~ 5mg IV morphine ~ 1mg IV dilaudid (give or take, depending on what conversion tables you use)

 

[thegenius]

I have always assumed that those were red herrings and that the pain was from a different cause.

Correct, kidney stones in the cortex don't cause pain. In fact it just confuses people so I never tell them they have one. They either have an obstructing kidney stone, or one that's in the ureter that's flipped in a way that AT THAT MOMENT is not causing obstruction. I warn them....the pain train is gonna come! TOOT! TOOT! The pain train's coming TOOOOOOOOOT!

 

[deleted836128]

Me too. I feel bad for kidney stone pain.

However, can someone do a study for why people with kidney stones still in the kidney have pain. Theoretically they shouldn’t have pain unless there is a stone on the way out or just recently passed.

... they do?

 

[deleted836128]

Correct, kidney stones in the cortex don't cause pain. In fact it just confuses people so I never tell them they have one. They either have an obstructing kidney stone, or one that's in the ureter that's flipped in a way that AT THAT MOMENT is not causing obstruction. I warn them....the pain train is gonna come! TOOT! TOOT! The pain train's coming TOOOOOOOOOT!

That’s why I usually tell them they have a ureteral stone and then give them an anatomy lesson!

 

[NITRAS]

I stopped using oxycodone, and use hydromorphone tablets with scheduled Tylenol +/- ibuprofen. There’s at least one study that shows metabolites buildup in renal insufficiency with oxycodone. Morphine sulphate is fine, but I don’t like the 15mg tabs. Our palliative care guys love the 20mg/ml solution because it has some buccal absorption.

 

[KGflyboy]

Can't say this has been my experience. Haven't fixed a single renal colic with toradol alone. Plus in that 10 minutes, they will be writhing around doing the kidney stone dance. I've had females with renal colic tell me the pain was worse than going into labor. That sounds quite miserable, and I can't see how toradol alone would make that disappear.

That's interesting. I have had many people who I initially gave IV narcotics still have a lot of pain. Then when I give IV toradol the pain pretty much resolves. I would say toradol works better than opiates for more than half the patients I see with kidney stones.

People often thank me and think I have them some magic potion because they can't believe how much better they feel.

 

[Rendar5]

NSAID + opioid provides more effective renal colic relief than NSAID or opioid alone. I never initially give iv narcotics alone unless there’s an nsaid allergy. I sometimes give toradol alone effectively if they’re not writhing around. So from my experience in terms of pain relief: toradol + opioid > toradol > opioid