Renal pain is one of the most severe types of pain which occurs in humans.  However, narcotics are clearly inferior for the severe pain of renal colic, as proven by numerous studies.  Yet, hundreds of thousands of patients are forced to suffer excruciating pain and also become primed for narcotic addiction simply because their doctors are ignorant of the research or don't care.

For treating kidney stone pain, the narcotics' track record is 0 wins, 12 losses, and 5 ties.  Narcotics are losers.

Fentanyl: For Lithotripsy, Ketorolac Did as Well for Pain with Many Fewer Side-Effects and Much Faster Discharge: In a DB study of 60 patients undergoing extracorporeal shock wave lithotripsy, IV ketorolac 60 mg 30 min before ESWL did as good as relieving pain and with fewer side-effects and earlier discharge time than fentanyl 100 mcg 3 min before ESWL. All patients received 2.5 mg midazolam IV 3 min before ESWL for intraoperative sedation. The incidence of oxygen supplement was much lower in ketorolac group (1/30) compared with that of fentanyl group (20/30), P < 0.01. The frequency of dizziness was much lower in ketorolac group (1/30) than that in fentanyl group (25/30), P < 0.01. Three patients in fentanyl group complained of nausea, but none did in ketorolac group. The discharge time from PAR was much shorter in ketorolac group (15 min) than that in fentanyl group (50 min), P < 0.01. Effects of intravenous ketorolac and fentanyl combined with midazolam on analgesia and side effects during extracorporeal shock wave lithotripsy. Yang, CP, et al. National Defense Medical Center,  Taipei, Taiwan, R.O.C., Acta Anest Sin 2002 Mar;40(1):9-12.

Ketogan: NSAID Voltaren as Good as Narcotic Ketogan, But with Fewer Side-Effects: In a DB study of 56 patients with renal or ureteric colic, IM Voltaren did just as well as IM Ketogan (ketobemidone), a European narcotic similar to meperidine. There were no significant differences regarding pain-relief but side effects were fewer in patients treated with Voltaren. Analgesic effect and tolerance of Voltaren and Ketogan in acute renal or ureteric colic. Sommer P, et al. Copenhagen County Hospitals, Gentofte, Denmark. Br J Urol 1989 Jan;63(1):4-6.

Hydromorphine (Dilaudid) Inferior to IV Indomethacin: In a DB study of 50 patients with acute ureteral-stone pain, IV indomethacin 50 mg provided more rapid pain relief than SC 2 mg hydromorphine chloride-atropine (Dilaudid-atropine 1 ml). Patients in the latter group also received a suppository of prochlorperazine 25 mg. The side-effects of indomethacin had a tendency to be milder and of shorter duration. Uden P, Rentzhog L, Berger T. A comparative study on the analgesic effects of indomethacin and hydromorphine chloride-atropine in acute, ureteral-stone pain. Acta Chirurgica Scandinavica 1983;149(5):497{9. 6637313.

Meperidine: Ketorolac More Effective and Quicker Discharge: In a DB PC study of renal colic in 70 emergency room patients, 60 mg of ketorolac was more effective than 100 to 150 mg meperidine (P < .05) at 40, 60, and 90 minutes. Of patients who were discharged home, those treated with ketorolac left the ER significantly earlier than those treated with meperidine (3.46 v 4.33 h, P < .05). Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. Larkin GL, et al. Mercy Hospital of Pittsburgh, University of Pittsburgh. Am J Emerg Med 1999 Jan;17(1):6-10.

Meperidine: IV Indomethacin as Good as Meperidine: In a DB study of 150 patients with acute renal colic, IV lysine acetylsalicylate 1.8 g was less effective than IV indomethacin 100 mg and IV meperidine 100 mg which did equally well. Comparative study of the efficacy of lysine acetylsalicylate, indomethacin and pethidine in acute renal colic. al-Sahlawi KS, et al. Mubarak Al-Kabeer Hospital, Kuwait. Eur J Emerg Med 1996 Sep;3(3):183-6.

Meperidine: IV Ketorolac as Good as IV Meperidine and Combination was No Better: In a DB study of 154 adults with renal colic, IV ketorolac 60 mg did significantly better than meperidine 50 mg.  Both combined did no better than ketorolac alone for pain relief and time elapsed before the need for supplemental meperidine. By 30 minutes, 75% of the ketorolac group and 74% of the combination group had a 50% reduction in pain scores, compared with 23% of the meperidine group (P < .001). Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic. Cordell WH, et al. Methodist Hospital of Indiana. . Ann Emerg Med 1996 Aug;28(2):151-8.

Meperidine: Ketorolac Did Better for Pain than Meperidine with Fewer Side-Effects: In a DB study of 76 adults with renal colic, ketorolac 30 mg IM did better than meperidine 100 mg IM. 88% of each group and less pain at 1 hour, but the summed pain intensity favored ketorolac (P < 0.05). Additional pain medication was requested by 56% of ketorolac and 74% of meperidine patients. Side-effects were lower with ketorolac 28% vs. 51%. A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic. Sandhu DP, et al. Leicester General Hospital, UK. Br J Urol 1994 Dec;74(6):690-3.

Meperidine: Diclofenac and NSAID Dipyrone Both Did as Well Meperidine in Large Study: In a DB study of 451 patients with renal colic, IM dipyrone 1 and 2 g, IM diclofenac and IM meperidine were compared. Rescue treatment was required in 93 patients: 24% given dipyrone 1 g; 22% given dipyrone 2 g; 16% given diclofenac; and 19% given pethidine. The authors conclude, " Diclofenac sodium is a valid alternative, which shows similar analgesic efficacy." Comparative study of the efficacy of dipyrone, diclofenac sodium and pethidine in acute renal colic. Collaborative Group of the Spanish Society of Clinical Pharmacology. Eur J Clin Pharm 1991;40(6):543-6.

Meperidine: IM Ketorolac 90 mg Better than IM Meperidine 100 mg: In a DB study of 121 patients with moderate to severe renal colic pain, IM ketorolac 90 mg did better than IM meperidine 100 mg although the differences were not statistically significant. Many fewer patients given ketorolac 90 mg (17%) required a further dose of analgesic within 10 hours than with ketorolac 10 mg (39%) or meperidine 100 mg (47%). The difference was statistically significant. The authors conclude, "IM ketorolac is efficacious in the treatment of renal colic." A double-blind single dose comparison of intramuscular ketorolac tromethamine and pethidine in the treatment of renal colic. Oosterlinck W, et al. University Hospital, Ghent, Belgium. J Clin Pharm 1990 Apr;30(4):336-41.

Meperidine Inferior to Diclofenac: In two single-blind, randomized studies totalling 207 patients with renal colic of single intramuscular doses of diclofenac (75 mg) versus a dipyrone (1 g)/spasmolytics combination, and a second study of diclofenac (75 mg) versus pethidine (meperidine) (75 mg), patients treated with diclofenac showed an earlier onset of analgesia and a higher incidence of total pain relief compared to those treated with dipyrone/spasmolytics or pethidine. Although the mean duration of analgesia was only slightly greater for diclofenac than dipyrone/spasmolytics, a significantly longer effect was seen for diclofenac vs. pethidine (p less than 0.01). Pain relief was greater with diclofenac after 60 minutes vs. dipyrone/spasmolytics (p less than 0.05) and after 30 minutes vs. pethidine (p less than 0.05). Global efficacy assessments by the physician rated diclofenac superior to dipyrone/spasmolytics (p less than 0.01) and pethidine (p less than 0.001). Diclofenac sodium was better tolerated than either of the others. Marthak KV, Gokarn AM, Rao AV, Sane SP, Mahanta RK, Sheth RD, et al. Bombay, India. A multi-centre comparative study of diclofenac sodium and a dipyrone/spasmolytic combination, and a single-centre comparative study of diclofenac sodium and pethidine in renal colic patients in India. Current Medical Research & Opinion 1991;12(6):366{73) 2044396.

Meperidine Inferior to Rectal Diclofenac: This DB study compared IV meperidine to rectal diclofenac. Thompson JF, Pike JM, Chumas PD, Rundle JS. Rectal diclofenac compared with pethidine injection in acute renal colic. BMJ 1989;299(6708):1140{1. 2513026.

Oxycodone No Better Than Indomethacin for Renal Colic: In a DB, cross-over study of 61 patients with acute renal colic, indomethacin 50 mg IV did just as well as oxycodone-papaverine 5 mg + 50 mg IV. For those patients requiring a second injection the drugs were reversed. The intensity of pain was evaluated before and 20 min after each injection according to an analogue visual scale 0 to 100. Both drug regimens provided comparable and significant pain relief; a pain score of less than 20 appeared to be satisfactory and was achieved in almost all cases. Intravenous indomethacin and oxycone-papaverine in the treatment of acute renal colic. A double-blind study. Jonsson PE, et al. Br J Urol. 1987 May;59(5):396-400.

Oxycodone Worse Than Indoprofen: In a DB study of 94 patients with severe acute renal colic pain, Intravenous indoprofen (400 mg), did better than intramuscular oxycodone 10 mg with papaverine (20 mg). More patients required additional treatment in the oxycodone than in the indoprofen group (19 v. 10). At 2-5 min after injection, pain reduction was greater with indoprofen, and more patients in this group had pain relief after 3-5 hours. Side effects were less frequent with indoprofen than with oxycodone (1 v. 20 patients), in particular from the central nervous system. This difference probably was related to indoprofen's slow and poor penetration of the blood-brain barrier. Comparison of a narcotic (oxycodone) and a non-narcotic anti-inflammatory analgesic (indoprofen) in the treatment of renal colic. Persson NH, et al. Acta Chir Scand. 1985;151(2):105-8.

Tramadol Inferior to NSAID Dipyrone: In a DB study of 104 patients suffering from "severe" to "excruciating" colic pain due to a confirmed kidney stone in the ureter, IV 2.5 g dipyrone was more effective for reducing pain than IV 100 mg tramadol, or IV 20 mg butylscopolamine. Only 5 patients receiving dipyrone needed "rescue" medication as compared with 13 patients given tramadol and 11 patients receiving butylscopolamine. Butylscopolamine did non-significantly Better than tramadol. Double-blind study with dipyrone versus tramadol and butylscopolamine in acute renal colic pain. Stankov G, et al.  DIAS Institute, Kirchheim/Munchen, Germany. World J Urol 1994;12(3):155-61.

Tramadol SC Inferior to Ketorolac IM: This is a DB study with good outcome measures. Nicolas Torralba JA, RigabertMontiel M, Banon Perez V, Valdelvira Nadal P, Perez Albacete M. Intramuscular ketorolac compared to subcutaneous tramadol in the initial emergency treatment of renal colic [Ketorolaco intramuscular frente a Tramadol subcutaneo en el tratamiento inicial de urgencia del colico renal]. Archivos Espanoles de Urologia 1999;52(5):435{7. 10427881.

Review Study Found 13 Studies: Opiates Had Less Pain Relief with More Side-Effects: Holdgate and Pollock identified studies that compared NSAIDs with opiates in adults with acute renal colic (fewer than 12 hours' duration) and moderate to severe pain. They found 20 studies that included a total of 1,613 patients and compared a total of five NSAIDs and five opiates (each study compared one opiate with one NSAID). Pain scores were reported in 13 studies. Ten studies found that patients who took NSAIDs had lower pain scores; two studies found no difference, and one study reported lower pain scores in patients who took opiates. NSAID patients were 25% less likely to use rescue medication. Vomiting was much more common in patients randomized to opiates (19.5 versus 5.8 percent; P < .00001; number needed to harm, seven). Overall, NSAIDs had 43% fewer side-effects. MARK H. EBELL, M.D., M.S. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev 2004;(3):CD004137. Ed: While these authors report that Larkin ('99) favored in opiate, the actual report from Larkin noted above very clearly favors ketorolac.

Opiate Inferior to IV Tenoxicam: Curry C, Kelly AM. Intravenous tenoxicam for the treatment of renal colic. New Zealand Medical Journal 1995;108(1001):229{30)7603654.

Thomas E. Radecki, M.D., J.D.

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