SLR - July 2018 - Josephine P. Lyons
Reference: Poonai N, Datoo N, Ali S, Cashin M, Drendel AL, Ahu R, Lepore N, Greff M, Rieder M, Bartley D. Oral Morphine Versus Ibuprofen Administered at Home for Postoperative Orthopedic Pain In Children: A Randomized Controlled Trial. CMAJ. 2017 Oct; 40(189) E1252-8.Scientific Literature Review
Reviewed By: Josephine P. Lyons, DPM
Residency Program: Columbia St. Mary’s, Milwaukee, WI
Podiatric Relevance: NSAID versus opioid pain medication is a hotly debated topic among surgeons. The recent push for fewer narcotic prescriptions also makes the debate a more relevant topic of discourse. Many patients resist taking narcotics due to their potential for adverse side effects or their addictive properties. Other patients resist taking NSAIDs due to GI issues or because they believe this class of medication will not be sufficient to provide pain relief. There is also a lack of data for pediatric populations. This study attempts to evaluate which medication is more effective for at-home postoperative pain control in children.
Methods: This is a randomized controlled trial conducted at Children’s Hospital in London, Ontario. One hundred thirty-two patients ages five to 17 were randomized by the hospital pharmacy using 1:1 allocation to receive either oral morphine (0.5 mg/kg, max 20 mg) and placebo ibuprofen or oral ibuprofen (10mg/kg, max 600mg) and placebo morphine. Patients could take a dose every six hours PRN pain for the first 48 hours with a maximum allocation of eight doses. Patients were also allowed to take Tylenol 15 mg/kg if pain persisted for 60 minutes after intervention. Patients rated pain immediately before and 30 minutes after dosing based on the Faces Pain Scale. The primary outcome was the pre-post difference in first dose reported pain. Secondary outcomes were pain for the second to eighth doses, number of patients requiring acetaminophen, unscheduled visits to a provider and adverse effects.
Results: Allocation: 65 patients oral morphine and 67 oral ibuprofen. The study found in the morphine group: average time to intervention was 3.3 hours with preintervention pain score average of 3 and postintervention score of 1. In the ibuprofen group, the average time to intervention was 3.5 hours with average preintervention pain score of 3 and postintervention score of 1. The pain scores for doses two to eight of each group were comparable and not statistically significant. There were 18 patients in the morphine group and 26 in the ibuprofen group who required additional acetaminophen for pain control. The oral morphine group reported more adverse side effects, including nausea, vomiting, drowsiness, dizziness and constipation (69 percent, 45/65 participants), than the oral ibuprofen group (39 percent, 26/67 participants).
Conclusions: The authors concluded that both medications are equally effective in reducing postoperative pain (although neither provided complete analgesia), but there were more adverse events in the oral morphine group. Pain scores dropped an average of one point with each dose. The authors also discussed that ibuprofen may be more acceptable to caregivers of children, but there were some participants who withdrew because they believed that ibuprofen would not adequately control pain. Authors also noted a high correlation of postop pain levels with anxiety. There are several limitations to this study, including the variety of procedures performed (injection to ORIF) and the pediatric population, as well as the dosing difference in medications. However, the study at present supports other evidence that ibuprofen and acetaminophen are sufficient to provide analgesia during the postop timeframe.