Oral Morphine Plus Ibuprofen Inadequate for Pain in Kids in ED

Veronica Hackethal

October 12, 2017

Combined oral morphine plus oral ibuprofen does not provide adequate pain relief in children with musculoskeletal injuries treated in the emergency department (ED), according to results from the OUCH trial published online October 11 in Pediatrics.

The study looked at three ways of relieving pain — combined oral morphine with oral ibuprofen, oral morphine alone, and oral ibuprofen alone — and found that none of these medications was optimal for treating acute musculoskeletal pain in the children's ED.

"When you have severe acute pain, especially related to a fracture, you need proper pain management," first author Sylvie Le May, RN, PhD, from the University of Montreal in Quebec, Canada, told Medscape Medical News. "Pain needs to be managed quickly and with a combination of fast-acting medication and slow-acting or normal acting medication. That would be a better combination than oral medication only."

Although musculoskeletal injuries represent one of the major reasons children visit the ED, their pain often goes inadequately managed, according to Dr Le May and colleagues. One study showed that only about 35% of children seen in Canadian pediatric EDs for severe sprains or fractures even receive pain control.

For treating acute musculoskeletal pain in the ED, Dr Le May stressed the value of opioids, when properly administered. Given the current opioid epidemic in the United States and Canada, she acknowledged that providers may be reluctant to administer opioids to children. However, she pointed out that none of the nearly 500 children in this study experienced serious adverse effects.

"Our study focused on treatment in the ED. Within the context of the ED, I think that properly managing a child's pain requires an opioid, such as a fast-acting intranasal opioid, combined with another medication," she said.

That said, she is more cautious about sending children home with a prescription for narcotics, because of the risk for overdose or nefarious use.

"At discharge I would probably prescribe oral [nonsteroidal anti-inflammatory drugs], Motrin or Advil, or a combination with Tylenol," she said.

Ibuprofen Inadequate

Although ibuprofen is the standard first-line medication for treating musculoskeletal pain in children, studies have suggested that it alone may not provide adequate pain relief. Nonsteroidal anti-inflammatory drugs combined with oral opioids are most often used in the ED to treat fracture pain in children. However, little evidence supports one method over another.

Cross-study comparison is difficult because of differences in research methods. For example, studies have used different types of medication (fast-acting vs normal-acting), and no standardized pain scale exists for children. Also, some studies have measured pain before oral morphine reaches its peak action, at about 60 minutes. Doing so may underestimate its analgesic effect, Dr Le May explained.

To investigate the issue, the researchers conducted a randomized double-blind placebo-controlled trial at three hospitals in Montreal, Edmonton, and Ottawa, Canada. They enrolled children aged 6 to 17 years who were treated in the ED with acute musculoskeletal injuries. Researchers randomly assigned participants to oral morphine (0.2 mg/kg) plus oral ibuprofen (10 mg/kg), oral morphine (0.2 mg/kg) plus placebo, or oral ibuprofen (10 mg/kg) plus placebo.

Children self-reported their pain using the visual analog scale, a pain scale currently recommended for this age group. The primary outcome was decrease in pain score to less than 30 mm (indicating mild pain) 60 minutes after receiving medication. The analysis included 456 participants.

At baseline, participants had a mean pain score of 60.9, indicating moderate pain.

Results showed that none of the groups achieved adequate pain control, and that the difference between the groups was not statistically significant.

In the morphine plus ibuprofen group, only 29.9% achieved VAS below 30 mm, as did 29.3% in the morphine group and 33.0% in the ibuprofen group (P = .81).

No children in any of the groups reported serious adverse events. However, the morphine plus ibuprofen (21.5%) and morphine alone (20.7%) groups experienced more adverse events than the ibuprofen group (6.6%; both comparisons, P < .001). From 2% to 6% of the morphine groups reported nausea, abdominal pain, and drowsiness, whereas none of those in the ibuprofen-only group reported those symptoms.

The authors mentioned that the lack of difference between groups may be related to the morphine dose used in the study (0.2 mg/kg). This dose is at the low end of the recommended range for children (0.2 - 0.5 mg/kg), and may not be high enough to achieve adequate pain control for some children.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 11, 2017. Abstract

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