Hitting them where it hurts? Low dose nalbuphine therapy

Abstract

Objective: To determine if low dose nalbuphine provides an adequate reduction in pain with minimal side effects. Methods: Prospective cohort of 115 patients given nalbuphine by paramedics in Wales and the English borders. Outcome measures: (1) Mean total dose of nalbuphine administered, change in pain score, time to adequate pain relief (score below four), and change in respiratory rate and systolic blood pressure; (2) proportion of patients continuing to suffer moderate to severe pain on arrival at hospital; (3) incidence of adverse events. Results: Full data were obtained for all patients. The mean total dose of nalbuphine administered was 6.09 mg (range 2.5 to 12.5 mg). This was significantly higher in trauma than ischaemic chest pain patients (7.03 versus 5.13 mg). The mean reduction in pain score was −3.97 (95% CI −4.38 to −3.57, p<0.001). The mean time to adequate pain relief (where this was achieved) was 15.7 minutes (95% CI 13.4 to 17.9 minutes). On arrival at hospital 60% of patients (n=69, 95% CI 50.9 to 68.5%) still met ambulance criteria for analgesia (70.7% of trauma patients and 49.1% with ischaemic chest pain). Systolic blood pressure fell by a mean of −3.67 (95% CI −6.76 to −0.58, p=0.02) and respiratory rate increased by a mean of 1.63 (95% CI 1.08 to 2.17, p<0.001). Two patients complained of nausea (1.74%, 95% CI 0.5 to 6.0%). No other adverse events were reported. Conclusion: Low dose nalbuphine results in few adverse events, but offers poor pain control for a high proportion of patients. RESEARCH OBJECTIVESResearch question Does a low dose nalbuphine dosing regimen provide an adequate reduction in pain score with minimal side effects? Research aimsTo determine: (1) the mean total dose of nalbuphine administered; (2) the mean change in pain score; (3) the mean time to adequate pain relief (pain score below four) from the start of the first dose; (4) the proportion of patients continuing to suffer moderate to severe pain on arrival at hospital; (5) the proportion of patients receiving further analgesia after hospital admission; (6) the mean post-nalbuphine change in: (a) respiratory rate; (b) blood pressure; (7) the incidence of adverse events such as nausea, vomiting or dizziness. BACKGROUND

Less IS less: a randomised controlled trial comparing cautious and rapid nalbuphine dosing regimens

“…The incidence of nausea or vomiting was higher in this trial (21% v 16% for rapid and cautious regimen respectively) than in a previous low dose study, 6 suggesting a dose related effect.…”

“…Based on a 1.74% incidence of nausea in a previous study, 6 152 subjects were required in total to detect a between groups difference of 10% with an a of 5% and a power of 90% (x 2 test).…”

“…5 A subsequent survey of 115 patients treated with a conservative regimen (mean dose 6 mg) reported no clinically significant changes in respiratory rate or blood pressure and a mean decrease in pain score of four on a 10 point scale, although analgesia was inadequate for 60% of patients. 6 This study aimed to determine whether a cautious or rapid nalbuphine regimen combined the greater analgesic effect with the minimum of adverse events.…”

P Rehospital P Ain M Anagement

“…Given parenterally, onset of analgesia can be as short as 90 seconds. 58 The respiratory depression seen with fentanyl is less than with morphine.…”

Effects of nalbuphine on anterior pituitary and adrenal hormones and subjective responses in male cocaine abusers

“…The analgesic potency of nalbuphine is essentially equivalent to that of morphine on a weight basis (Errick and Heel, 1983;Miller, 1980;Zacny et al, 1997). Nalbuphine is used primarily for the management of pre-and postoperative pain, but is also used as an analgesic during labor and delivery (Cohen et al, 1992), after myocardial infarction (Jamidar et al, 1987), and as a parenteral analgesic by paramedics in the prehospital setting (Woollard et al, 2002). Administration of nalbuphine causes some respiratory depression similar to that induced by morphine (Lake et al, 1984).…”