Randomized Double-Blind Placebo-Controlled Trial of Two Intravenous Morphine Dosages (0.10 mg/kg and 0.15 mg/kg) in Emergency Department Patients With Moderate to Severe Acute Pain

Birnbaum, Adrienne; Esses, David; Bijur, Polly E.; Holden, Lynne; Gallagher, E. John

doi:10.1016/j.annemergmed.2006.06.030

Cited by 61 publications

(46 citation statements)

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“…10,11 IV morphine is titratable, allowing customized delivery for individual patients. Oral opioids are also used frequently in the treatment of pain in the ED, often in combination with acetaminophen (e.g., Percocet).…”

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confidence: 99%

Oral versus Intravenous Opioid Dosing for the Initial Treatment of Acute Musculoskeletal Pain in the Emergency Department

Miner

Moore

Gray

et al. 2008

Academic Emergency Medicine

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Objectives: The objective was to compare the time to medication administration, the side effects, and the analgesic effect at sequential time points after medication administration of an oral treatment strategy using oxycodone solution with an intravenous (IV) treatment strategy using morphine sulfate for the initial treatment of musculoskeletal pain in emergency department (ED) patients.Methods: This was a prospective randomized clinical trial of patients >6 years old who were going to receive IV morphine sulfate for the treatment of musculoskeletal pain but did not yet have an IV. Consenting patients were randomized to have the treating physician order either 0.1 mg ⁄ kg morphine sulfate IV or 0.125 mg ⁄ kg oxycodone orally in a 5 mg ⁄ 5 mL suspension as their initial treatment for pain. The time from the placement of the order to the administration of the medication was recorded. Pain was measured using a 100-mm visual analog scale (VAS) and recorded at 0, 10, 20, 30 and 40 minutes after drug administration.Results: A total of 405 eligible patients were identified during the study period; 328 (81.0%) patients consented to be in the study. A total of 158 patients were randomized to the IV morphine sulfate treatment group, and 162 were randomized to the oral oxycodone treatment group. Of the patients who were randomized to IV therapy, 34 were withdrawn from the study prior to drug administration; leaving 125 patients in the IV group for analysis. Of the patients who randomized to oral therapy, 22 were withdrawn from the study prior to drug administration, leaving 140 patients for analysis. No serious adverse events were detected. There was a 12-minute difference between the median time of the order and the administration of oral oxycodone (8.5 minutes) and IV morphine (20.5 minutes). The mean percent change in VAS score was larger for patients in the IV therapy group than those in the oral therapy group at 10 and 20 minutes. At 30 and 40 minutes, the authors could no longer detect a difference. The satisfaction scale score was higher after treatment for the morphine group (median = 4; interquartile range [IQR] = 4 to 5) than for the oxycodone group (median = 4; IQR = 2 to 5; p = 0.008). Conclusions:The oral loading strategy was associated with delayed onset of analgesia and decreased patient satisfaction, but a shorter time to administration. The oral loading strategy using an oxycodone solution provided similar pain relief to the IV strategy using morphine 30 minutes after administration of the drug. Oral 0.125 mg ⁄ kg oxycodone represents a feasible alternative to 0.1 mg ⁄ kg IV morphine in the treatment of severe acute musculoskeletal pain when difficult or delayed IV placement greater than 30 minutes presents a barrier to treatment.ACADEMIC EMERGENCY MEDICINE 2008; 15:1234-1240

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Oral versus Intravenous Opioid Dosing for the Initial Treatment of Acute Musculoskeletal Pain in the Emergency Department

Miner

Moore

Gray

et al. 2008

Academic Emergency Medicine

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“…Two other measures based on the NRS that have been used in other studies, [14][15][16][17] plus categorical descriptors of pain at 30 minutes after initiation of treatment, also indicated better pain control in the patients who received 2 mg IV hydromorphone. The proportion of patients who achieved a 50% or greater proportionate decrease in NRS pain score, an absolute NRS score of 3, or described their pain as "none" or "mild" at 30 minutes, was about 15% higher in the 2 mg hydromorphone group compared to the usual care group.…”

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confidence: 99%

“…Secondary efficacy outcomes, all of which were determined a priori and measured concurrently with the primary outcome at 30 minutes, included change in NRS, proportion of patients achieving ! 50% decline in NRS, 14,15 proportion of patients achieving an absolute NRS score 3, 16,17 and proportion of patients' describing their pain as "none" or "mild" (in contrast to descriptions of "moderate" or "severe" on a modified four-category Likert scale). The primary safety outcome was use of naloxone at any point during the study, which could be given for any reason as determined by ED attending judgment.…”

Section: Methodsmentioning

confidence: 99%

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Randomized Clinical Trial of Efficacy and Safety of a Single 2‐mg Intravenous Dose of Hydromorphone Versus Usual Care in the Management of Acute Pain

Chang

Bijur

Lupow

et al. 2013

Academic Emergency Medicine

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Objectives: The objective was to test the efficacy and safety of 2 mg of intravenous (IV) hydromorphone (Dilaudid) against "usual care" in emergency department (ED) patients with acute severe pain.Methods: This was a randomized clinical trial. Patients allocated to 2 mg of IV hydromorphone received their medication in a single dose. Those randomized to usual care received any IV opioid, with type, dose, and frequency chosen by the ED attending. All patients received 2 L/min. nasal cannula oxygen. The primary outcome was the difference in the proportion of patients who achieved clinically satisfactory analgesia by 30 minutes. This was defined as the patient declining additional analgesia when asked the question, "Do you want more pain medicine?" A 10% absolute difference was chosen a priori as the minimum difference considered clinically significant.Results: Of 175 subjects randomized to each group, 164 in the 2 mg hydromorphone group and 161 in the usual care group had sufficient data for analysis. Additional pain medication was declined by 77.4% of patients in the 2 mg hydromorphone group at 30 minutes, compared to 65.8% in the usual care group. This difference of 11.6% was statistically and clinically significant (95% confidence interval [CI] = 1.8% to 21.1%). Safety profiles were similar and no patient required naloxone. There was more pruritus in the hydromorphone group (18.3% vs. 8.7%; difference = 9.6%, 95% CI = 2.6% to 16.6%).Conclusions: Using a simple dichotomous patient-centered endpoint in which a difference of 10% in proportion obtaining adequate analgesia was considered clinically significant, 2 mg of hydromorphone in a single IV dose is clinically and statistically more efficacious when compared to usual care for acute pain management in the ED.ACADEMIC EMERGENCY MEDICINE 2013; 20:185-192

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“…Using the example of morphine, the literature (combined with clinical experience) provides a ready explanation. It is well known that many (if not most) ED patients will not achieve full pain relief with initial morphine doses up to 0.15 mg/kg [31]. Therefore it makes little sense to give an adult 8-10 mg of morphine and then switch to a different agent because of "treatment failure. "…”

Section: Keep It Simplementioning

confidence: 99%

Management of Pain in the Emergency Department

Thomas

2013

ISRN Emergency Medicine

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Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.

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Randomized Double-Blind Placebo-Controlled Trial of Two Intravenous Morphine Dosages (0.10 mg/kg and 0.15 mg/kg) in Emergency Department Patients With Moderate to Severe Acute Pain

Cited by 61 publications

References 20 publications

Oral versus Intravenous Opioid Dosing for the Initial Treatment of Acute Musculoskeletal Pain in the Emergency Department

Oral versus Intravenous Opioid Dosing for the Initial Treatment of Acute Musculoskeletal Pain in the Emergency Department

Randomized Clinical Trial of Efficacy and Safety of a Single 2‐mg Intravenous Dose of Hydromorphone Versus Usual Care in the Management of Acute Pain

Management of Pain in the Emergency Department

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