Navigating Nephrolithiasis: A Pharmacist's Perspective

Meeting Jason on Friday the 13th, marathon emergency room (ER) waits, reflections of Popeye—these are all things patients might experience when dealing with pain, on top of the discomfort of the sensation itself. Or at least, such was the case for Mark Garofoli, PharmD, MBA, BCGP, CPE, CTTS, professor at WVU School of Pharmacy, host of the Pain Pod, and alternatively known as the Pain Guy, when seeking care for nephrolithiasis at the start of the COVID-19 pandemic.

Illustration of kidney stones / Crystal light - stock.adobe.com

At this year's PAINWeek National Conference, held September 3 to 6 in Las Vegas, Nevada, Garofoli hosted a session titled, "Never Again! Nephrolithiasis (Kidney Stone Pain Management)." With a call to "never again" endure kidney stone pain, he guided the audience through his own experience with nephrolithiasis and equipped health care professionals with the knowledge, tools, and skills to help patients who find themselves in his same situation.

In a conversation with Drug Topics, Garofoli provided an overview of his presentation. He spoke to the importance of balancing opioid use, promoting preventive measures, and fostering interdisciplinary collaboration in providing care for kidney stone pain, as well as emphasized the importance of storytelling to humanize patient experiences in health care.

READ MORE: Breaking the Pain Barrier in Men's Health

Drug Topics: Can you give a brief overview of your presentation at PAINWeek regarding helping patients in pain with nephrolithiasis?

Mark Garofoli, PharmD, MBA, BCGP, CPE, CTTS: This presentation was slightly unique in style in that the underlying theme was “storytelling” of my own personal journey with a kidney stone during early COVID times, all the ups and downs, without really holding anything back.

Essentially, while sitting on an ER gurney on Friday the 13th after my wife and son dropped me off (folks weren’t allowed in due to pandemic restrictions), the gentleman on the other side of the curtain experienced a major nervous breakdown requiring the entire ER staff to restrain him. I overheard their words to “Jason,” and I realized that I should start taking notes of my experience on my phone as this may turn into one heck of a story. Three months after I met Jason on Friday the 13th, I had myself much more than a story, and wanted fellow health care professionals to learn from the adventure.

As I talked through the journey in my PAINWeek 2024 presentation, there were educational interludes reviewing what health care professionals appropriately did or did not do through my own pain journey, [and] there’s learning within.

Drug Topics: Your presentation mentioned the comparison of kidney stone pain to other excruciating experiences. What are some of the unique challenges in managing pain that is so intense and unpredictable?

Garofoli: The challenge lies in realizing that there is no challenge whatsoever in realizing that one needs to help a patient experiencing incredible acute pain now, if not yesterday, yet one must have on-demand knowledge and experience to get that accomplished.

Most patients (humans) are not ready to “chill” when experiencing excruciating pain and thus getting relevant information needed to make the health care decisions (informed decisions) can many times be a tad bit more difficult.

For instance, I was in the ER on Friday the 13th at the beginning of a pandemic and was asked how to rate my pain. "Pain Guy" in pain! Inherently, my response began with a pause and a stare before unraveling with an answer of 8.5, attempting to account for broken femurs, childbirth, and bear maulings, with a respective half-point each. Ask a dumb question, get a “dumb” answer, right?

Drug Topics: With the ongoing opioid crisis, how can health care professionals balance the need for effective pain management for nephrolithiasis with the risks associated with opioid use? What alternative therapies or approaches might be considered to reduce opioid dependence?

Garofoli: I had to endure 3 hours in a busy ER to finally have a CT scan performed to confirm what just about any respective health care professional could have presumed hours prior, to then finally be provided a ketorolac injection.

Ironically, 8 of the 183 randomized controlled trials contributing to the development of the 2022 CDC opioid guideline's first recommendation (of 12) involved kidney stone pain and highlighted that [nonsteroidal anti-inflammatory drugs] are typically the acute answer (yet patient specifics obviously matter as well). I invite readers to listen to my Pain Pod episodes on those guidelines, one being a succinct yet comprehensive review, with the other being an interview with the PharmD author of said guidelines.

Let’s get back to the question at hand, though. One of the most observed changes over the past few decades resonated when I was discharged with a prescription for a few acetaminophen/codeine (“T3”) tablets, as compared to the “old days” where the prescription would have most likely been for a few dozen tablets of a different prescription opioid. In all reality, that’s progress: Provide what’s reasonably needed to help a patient and do no harm, our most fundamental call to service.

Drug Topics: Your presentation highlighted the role of diet and lifestyle in preventing nephrolithiasis. How can pharmacists effectively educate patients about these factors and promote preventive measures?

Garofoli: Popeye. We all need to learn from Popeye, who reasonably should have had an oxalate kidney stone weekly given the amount of spinach he consumed. Luckily, he’s a fictitious cartoon, yet a character that now scares me to my core.

We, as pharmacists, can easily guide our patients who have experienced a kidney stone to have the follow-up care to prevent ever having one again, hence the presentation title “Never Again." Minimally, patients need to have a urology follow-up, most likely including a kidney stone analysis (deciphering the type), a 24-hour urine collection, amongst other lab efforts, to best find a path to “Never Again." In addition to those efforts, if a patient experienced an oxalate kidney stone, then it’s time to pause and figure out how to remove some oxalate heavy foods (spinach, rhubarb, etc) from one’s diet (and house) and train oneself to moderate those foods with appreciable amounts of oxalate.

Drug Topics: Given the complexity of managing nephrolithiasis, which involves pain management, nephrology, and potentially other specialties, how do you envision effective interdisciplinary collaboration to ensure optimal patient care?

Garofoli: Nephrolithiasis is a microcosm example of the absolute need for interprofessional care for the betterment of patient care.

For example, when I went from the ER to the local community pharmacy at 2:00 AM after my Friday the 13th ER adventure, I was asked to “sign here," the single most “insert negative word” experience a pharmacist as a patient can endure, skipping past “Do you have any questions?” [and] practically dismissing [The Omnibus Budget Reconciliation Act of 1990], while making patient care transactional. It would behoove one to minimally mention some anticipated side effects, whether sedation or opioid-induced constipation (particularly when already experiencing consternation in respect to urination).

Conversely, if the overall health care team were more connected, perhaps the treatment protocols could be updated to automatically include phenazopyridine to avoid a patient having a provider ask if he’s taking said medication which was never prescribed in the first place. Yup, my experience, fun. Let’s be real: Our health care system, like all on this planet, has its nuances, but the single most impactful pivot to the patient experience is cohesive dynamic interprofessional care. End rant, let’s go help patients, together!

Drug Topics: How do you believe sharing these stories can be effective in helping health care professionals understand the patient experience and improve their care?

Garofoli: Stories resonate with patients, really with anyone, much more than dictated facts or directions, as we're human, and we enjoy and recall stories much more than mundane instructions.

For instance, telling a patient to take a particular statin at bedtime is sometimes (hopefully) effective, but explaining that in a story fashion involving the "how" to go about that, including the storage, and preventing kid and pet access, and so on, can be much more effective if involving a person's story from the past. Just as I aimed to share the ups and downs of my COVID kidney stone story to highlight the little moments in health care that we health care professionals sometimes forget about, yet may be the most important in the eyes of our patients.

READ MORE: Pain Management Resource Center

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