Pain in Primary Care

Opioids vs NSAIDs for Nephrolithiasis

Charles P. Vega, MD


July 15, 2022

In May, I presented the case of Cristina, a 25-year-old primarily Spanish-speaking woman with severe, acute colicky left flank pain that radiated to her groin. She did not have health insurance and couldn't afford to miss many days of work as a caregiver.

After discussing cost-effective steps I would take to rule out ectopic pregnancy, make the diagnosis of nephrolithiasis, and formulate a treatment plan, I explored issues that put Cristina at risk for undertreatment of her pain, including racial and gender biases as well as and socioeconomic and language barriers.

I did not receive as many comments on Cristina's case as with previous case-based reviews on pain management. I believe that there are multiple potential reasons for the relatively quiet response. One of those reasons may be discomfort in discussing health disparities and biases in healthcare practice based on race and ethnicity. These are truths that are not easy to face, especially if you do not belong to a group that has traditionally experienced bias.

But speaking up, whether it is asking questions or making statements, is important. We cannot make progress on longstanding problems like racism and sexism without identifying them for what they are and then finding our own role in moving forward.

Are Opioids Necessary?

I very much appreciate the comments provided, and I will start with those of Dr Otte. You are right! I suggested giving Cristina a short course of opioids for her pain but the European Association of Urology (EAU) notes that nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol are effective for renal colic. These agents reduce the need for more analgesia, but the same cannot be said for opioids when applied to renal colic. Moreover, as in most pain conditions, NSAIDs are better tolerated than opioids, which are associated with high rates of nausea/vomiting.

The use of intramuscular NSAIDs has good evidence of efficacy for renal colic, but the EAU guidelines state that there is insufficient evidence to recommend one route of administration of NSAIDs over another. Clearly, in cases in which nausea/vomiting are prominent, a nonoral route is preferred.

However, the context of Cristina's case is important. Remember that she tried ibuprofen 400 mg several times at home with no improvement. It could still be worth a try to give a high-dose intramuscular NSAID, but she might do better on a short course of opioids, based on the ibuprofen failure. Perhaps an even better approach is to provide the high-dose NSAID with a low-dose opioid as a potential alternative.

With symptoms typical of renal colic and a urine dipstick negative for nitrite and white blood cells, I do not think a urine culture is necessary. Antibiotics would not be indicated routinely for this case.

The 'Latinx' Debate

Finally, we referred to Cristina as Latinx and I am happy to have the opportunity to address the longstanding controversy of labeling the Hispanic/Latino/Latinx/Latine ethnicity. Our reader is correct in that Latinx is not a preferred term in the community; many people from that community do not even recognize the term.

In a Gallup poll conducted in summer 2021, among persons identifying as Hispanic or Latino, 23% of respondents preferred the term "Hispanic"; 15% preferred "Latino"; and a very small proportion — just 4% — preferred "Latinx." What is not surprising to me is that the majority (57%) of respondents in this survey did not care which term was used. This reflects my experience with the community, where people will proudly call themselves Salvadoreña or Guatamalteco. Very few people say they are Mejicanos. But I hear folks all the time tell me, "Soy de Oaxaca" ("I'm from Oaxaca") or "Mi familia vino de Jalisco" ("My family came from Jalisco"). Mexico is a country of intense regional pride.

The terms "Latinx" and "Latine" do have a place because they do not promote binary gender choices inherent in the Spanish language. And that just creates greater inclusion in a vibrant culture. If people in the Latinx culture are not bothered by labels, why should they divide anyone else?

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