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Pharmacokinetics of Morphine Sulfate Orodispersible Tablets and Bioequivalence with Immediate-Release Oral Morphine Sulfate Formulations in Healthy Adult Subjects Under Fasting Conditions: Single-Dose Comparative Bioavailability Studies. Clin Drug Investig 2022; 42:1101-1112. [DOI: 10.1007/s40261-022-01214-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
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Rieder MJ, Jong G'. The use of oral opioids to control children's pain in the post-codeine era. Paediatr Child Health 2021; 26:120-127. [PMID: 33747307 DOI: 10.1093/pch/pxaa133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/06/2020] [Indexed: 11/14/2022] Open
Abstract
Pain is a common problem for children, and pain management comprises both pharmacologic and nonpharmacologic measures. For moderate to severe pain, oral opioids have been a popular choice for the last few decades. Codeine has historically been the best-known oral opioid for use in children. However, availability and use of codeine have sharply declined due to safety concerns. A variety of other opioids have been used in place of codeine, but data are limited regarding their efficacy and safety in children. While the same pathways metabolize oral oxycodone as codeine, oxycodone's pharmacokinetics varies widely. There are also limited data on the safety and efficacy of oral hydromorphone and tramadol use for children. Oral morphine is the opiate alternative to codeine for which there is the most evidence of safety and efficacy in children. Research is needed to investigate both other opioids and non-opioid approaches to guide evidence-based analgesic therapy and treatment for moderate-to-severe pain in children.
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Affiliation(s)
- Michael J Rieder
- Canadian Paediatric Society, Drug Therapy and Hazardous Substances Committee, Ottawa, Ontario
| | - Geert 't Jong
- Canadian Paediatric Society, Drug Therapy and Hazardous Substances Committee, Ottawa, Ontario
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Rieder MJ, Jong G'. Les opioïdes par voie orale en remplacement de la codéine pour contrôler la douleur chez les enfants. Paediatr Child Health 2021; 26:120-127. [PMID: 33747308 DOI: 10.1093/pch/pxaa134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/06/2020] [Indexed: 11/14/2022] Open
Abstract
La douleur est un problème courant chez les enfants. Des mesures pharmacologiques et non pharmacologiques sont utilisées pour la prendre en charge. Depuis quelques décennies, les opioïdes par voie orale sont populaires pour soulager la douleur modérée à grave. La codéine a longtemps été l'opioïde par voie orale le plus connu pour les enfants. Pour des raisons de sécurité, elle est désormais nettement moins accessible et moins employée. Divers autres opioïdes la remplacent, mais les données sur leur efficacité et leur sécurité sont limitées chez les enfants. L'oxycodone par voie orale emprunte les mêmes voies métaboliques que la codéine, mais sa pharmacocinétique est très variable. Les données sur la sécurité et l'efficacité de l'hydromorphone et du tramadol par voie orale chez les enfants sont également limitées. Lorsqu'on y recourt au lieu de la codéine, la morphine par voie orale est l'opiacé dont la sécurité et l'efficacité sont les mieux démontrées chez les enfants. Des recherches devront être réalisées pour explorer d'autres approches relatives aux médicaments opioïdes et non opioïdes, afin d'orienter les traitements analgésiques fondés sur des données probantes qui soulageront la douleur modérée à grave chez les enfants.
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Affiliation(s)
- Michael J Rieder
- Société canadienne de pédiatrie, comité de pharmacologie et des substances dangereuses, Ottawa (Ontario)
| | - Geert 't Jong
- Société canadienne de pédiatrie, comité de pharmacologie et des substances dangereuses, Ottawa (Ontario)
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Drendel AL, Ali S. Ten Practical Ways to Make Your ED Practice Less Painful and More Child-Friendly. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Le May S, Ali S, Plint AC, Mâsse B, Neto G, Auclair MC, Drendel AL, Ballard A, Khadra C, Villeneuve E, Parent S, McGrath PJ, Leclair G, Gouin S. Oral Analgesics Utilization for Children With Musculoskeletal Injury (OUCH Trial): An RCT. Pediatrics 2017; 140:peds.2017-0186. [PMID: 29021235 DOI: 10.1542/peds.2017-0186] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Musculoskeletal injuries (MSK-Is) are a common and painful condition among children that remains poorly treated in the emergency department (ED). We aimed to test the efficacy of a combination of an anti-inflammatory drug with an opioid for pain management of MSK-I in children presenting to the ED. METHODS In this randomized, double-blinded, placebo-controlled trial, we enrolled children between 6 and 17 years presenting to the ED with an MSK-I and a pain score >29 mm on the visual analog scale (VAS). Participants were randomly assigned to oral morphine (0.2 mg/kg) + ibuprofen (10 mg/kg) (morphine + ibuprofen) or morphine (0.2 mg/kg) + placebo of ibuprofen or ibuprofen (10 mg/kg) + placebo of morphine. Primary outcome was children with VAS pain score <30 mm at 60 minutes postmedication administration. RESULTS A total of 501 participants were enrolled and 456 were included in primary analyses (morphine + ibuprofen = 177; morphine = 188; ibuprofen = 91). Only 29.9% (morphine + ibuprofen), 29.3% (morphine), and 33.0% (ibuprofen) of participants achieved the primary outcome (P = .81). Mean VAS pain reduction at 60 minutes were -18.7 (95% confidence interval [CI]: -21.9 to -16.6) (morphine + ibuprofen), -17.0 (95% CI: -20.0 to -13.9) (morphine), -18.6 (95% CI: -22.9 to -14.2) (ibuprofen) (P = .69). Children in the morphine + ibuprofen group (P < .001) and in the morphine group (P < .001) experienced more side effects than those in the ibuprofen group. No serious adverse event was reported. CONCLUSIONS Combination of morphine with ibuprofen did not provide adequate pain relief for children with MSK-I in the ED. None of the study medication provided an optimal pain management because most of children did not reach a mild pain score (NCT02064894).
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Affiliation(s)
- Sylvie Le May
- Faculties of Nursing and .,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Samina Ali
- Women and Children's Health Research Institute, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Departments of Pediatrics and.,Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Benoit Mâsse
- CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Gina Neto
- Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Amy L Drendel
- Departments of Pediatrics and.,Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ariane Ballard
- Faculties of Nursing and.,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada.,Women and Children's Health Research Institute, Edmonton, Alberta, Canada
| | - Christelle Khadra
- Faculties of Nursing and.,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada.,Women and Children's Health Research Institute, Edmonton, Alberta, Canada
| | | | | | - Patrick J McGrath
- IWK Health Centre, Nova Scotia Health Authority and Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Serge Gouin
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada; and
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Poonai N, Datoo N, Ali S, Cashin M, Drendel AL, Zhu 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; 189:E1252-E1258. [PMID: 29018084 DOI: 10.1503/cmaj.170017] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Oral morphine for postoperative pain after minor pediatric surgery, while increasingly popular, is not supported by evidence. We evaluated whether oral morphine was superior to ibuprofen for at-home management of children's postoperative pain. METHODS We conducted a randomized superiority trial comparing oral morphine (0.5 mg/kg) with ibuprofen (10 mg/kg) in children 5 to 17 years of age who had undergone minor outpatient orthopedic surgery (June 2013 to September 2016). Participants took up to 8 doses of the intervention drug every 6 hours as needed for pain at home. The primary outcome was pain, according to the Faces Pain Scale - Revised, for the first dose. Secondary outcomes included additional analgesic requirements, adverse effects, unplanned health care visits and pain scores for doses 2 to 8. RESULTS We analyzed data for 77 participants in each of the morphine and ibuprofen groups. Both interventions decreased pain scores with no difference in efficacy. The median difference in pain score before and after the first dose of medication was 1 (interquartile range 0-1) for both morphine and ibuprofen (p = 0.2). For doses 2 to 8, the median differences in pain score before and after the dose were not significantly different between groups. Significantly more participants taking morphine reported adverse effects (45/65 [69%] v. 26/67 [39%], p < 0.001), most commonly drowsiness (31/65 [48%] v. 15/67 [22%] in the morphine and ibuprofen groups, respectively; p = 0.003). INTERPRETATION Morphine was not superior to ibuprofen, and both drugs decreased pain with no apparent difference in efficacy. Morphine was associated with significantly more adverse effects, which suggests that ibuprofen is a better first-line option after minor surgery. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01686802.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis.
| | - Natasha Datoo
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Megan Cashin
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Amy L Drendel
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Rongbo Zhu
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Natasha Lepore
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Michael Greff
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Michael Rieder
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Debra Bartley
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
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How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review. Pain Res Manag 2016; 2016:5346819. [PMID: 28077923 PMCID: PMC5203901 DOI: 10.1155/2016/5346819] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 10/18/2016] [Accepted: 10/27/2016] [Indexed: 11/18/2022]
Abstract
Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.
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Abstract
Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.
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Affiliation(s)
- Peter J. S. Koo
- Departments of Clinical Pharmacy and Pharmaceutical Services, University of California, San Francisco, San Francisco, California
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Le May S, Ali S, Khadra C, Drendel AL, Trottier ED, Gouin S, Poonai N. Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review. Pain Res Manag 2016; 2016:4809394. [PMID: 27445614 PMCID: PMC4904632 DOI: 10.1155/2016/4809394] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/03/2015] [Indexed: 12/21/2022]
Abstract
Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly. Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries. Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0-18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores. Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen. Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.
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Affiliation(s)
- Sylvie Le May
- Faculty of Nursing, University of Montreal, Montreal, QC, Canada H3T 1A8
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
| | - Samina Ali
- Women and Children's Health Research Institute, Edmonton, AB, Canada T6G 1C9
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada T6G 1C9
| | - Christelle Khadra
- Faculty of Nursing, University of Montreal, Montreal, QC, Canada H3T 1A8
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- McGill University Health Centre, Montreal, QC, Canada H4A 3J1
| | - Amy L. Drendel
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Evelyne D. Trottier
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- Division of Emergency Medicine, Department of Pediatrics, Sainte-Justine Hospital (CHU Sainte-Justine), Montreal, QC, Canada H3T 1C5
| | - Serge Gouin
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- Division of Emergency Medicine, Department of Pediatrics, Sainte-Justine Hospital (CHU Sainte-Justine), Montreal, QC, Canada H3T 1C5
| | - Naveen Poonai
- Children's Hospital, London Health Sciences Centre, London, ON, Canada N6A 5W9
- Schulich School of Medicine and Dentistry, London, ON, Canada N6A 5C1
- Child Health Research Institute, London, ON, Canada N6C 2V5
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Poonai N, Kilgar J, Mehrotra S. Analgesia for fracture pain in children: methodological issues surrounding clinical trials and effectiveness of therapy. Pain Manag 2015; 5:435-45. [DOI: 10.2217/pmt.15.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fractures in childhood are common painful conditions. Suboptimal analgesia has been reported in the emergency department and following discharge. Recently, concern about the safety of narcotics such as codeine has sparked a renewed interest in opioids such as morphine for pediatric fracture pain. Consequently, opioids are being increasingly used in the clinical setting. Despite this, there is ample evidence that clinicians are more willing to offer opioids to adults than children. The existence of limited evidence supporting their use in children is likely a major contributing factor. A closer look at the limitations of designing high-quality analgesic trials in children with fractures is needed to enable investigators to anticipate problems and clinicians to make evidence-based choices.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Paediatric Emergency Department, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jennifer Kilgar
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Shruti Mehrotra
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
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Poonai N, Bhullar G, Lin K, Papini A, Mainprize D, Howard J, Teefy J, Bale M, Langford C, Lim R, Stitt L, Rieder MJ, Ali S. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ 2014; 186:1358-63. [PMID: 25349008 DOI: 10.1503/cmaj.140907] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain. METHODS We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale - Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose. RESULTS We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre-post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) -0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI -0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ -0.1 [95% CI -0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI -0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01). INTERPRETATION We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01690780.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta.
| | - Gina Bhullar
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Kangrui Lin
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Adam Papini
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - David Mainprize
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Jocelyn Howard
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - John Teefy
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Michelle Bale
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Cindy Langford
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Rodrick Lim
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Larry Stitt
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Michael J Rieder
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
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Borland ML, Clark LJ, Esson A. Comparative review of the clinical use of intranasal fentanyl versus morphine in a paediatric emergency department. Emerg Med Australas 2008; 20:515-20. [DOI: 10.1111/j.1742-6723.2008.01138.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Goldman RD, Crum D, Bromberg R, Rogovik A, Langer JC. Analgesia administration for acute abdominal pain in the pediatric emergency department. Pediatr Emerg Care 2006; 22:18-21. [PMID: 16418607 DOI: 10.1097/01.pec.0000195761.97199.37] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To document the use of analgesia for children with acute abdominal pain in the Pediatric Emergency Department (PED) and to compare between children with suspected appendicitis in a high versus low probability. STUDY DESIGN Patients 0-16 years recruited prospectively as part of another PED study in Toronto. History of present illness and physical examination was available, and information on analgesia administered in the PED was retrospectively collected from charts. Physicians' probability of appendicitis before any imaging was recorded. A follow-up call was made to verify final diagnosis. RESULTS We included 438 patients, 16% with appendicitis. Analgesics were given 154 times to 112 patients. Thirty-one percent of the cohort received analgesia before seeing the physician, mostly febrile, 37% after seeing the physician, and 17% after seeing a pediatric-surgery consultant. Fifteen percent received multiple dosages. Underdosing was recorded in 14% of medications, mostly morphine (24%). Analgesia was given significantly more often to children with high probability of appendicitis. Age was not a factor in analgesia administration. CONCLUSION Children with abdominal pain receive more analgesia when the physician suspects appendicitis, yet only in half of the cases, and only 15% receive opioids. Opioid underdosing happens in a quarter of times it is given.
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Affiliation(s)
- Ran D Goldman
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Population Health Sciences, The Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Wille C, Bocquet N, Cojocaru B, Leis A, Chéron G. [Oral morphine administration for children's traumatic pain]. Arch Pediatr 2005; 12:248-53. [PMID: 15734118 DOI: 10.1016/j.arcped.2004.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Accepted: 07/27/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To study the compliance of prescription, the efficacity and the adverse events of oral morphine used in the pediatric emergency department (ED) in traumatic pains. METHOD This prospective study was conducted in the ED from october 2002 to september 2003. Children aged six months to 16 years with a visual analogic scale (VAS) score higher than 70 or with a traumatic member deformation received oral morphine (0,5 mg/kg). Pain was assessed every 30 minutes using two scales: behavioral observation by the faces scale and objective pain scale (OPS) for children less than five years, behavioral observation by the faces scale and self-report by VAS for children older than five years. The compliance of prescription, the pain scores and the adverse events were studied. RESULTS Ninety-one children received oral morphine and seventy-four children were studied. Seventy per cent of prescriptions were in accordance with the recommendations. For patients younger than five years a rapid decrease of pain was observed in thirty minutes. The pain's reduction was respectively 79 and 84% with faces scale and OPS when they left ED. For children older than five years, pain's reduction was more important and more rapid when pain assessment was made by nurses than when it was self-reported in the first hour (pain reduction 58,2 and 36,1%). When leaving, pain reduction was the same with the two different assessments. No major adverse event was noted. CONCLUSION Use of oral morphine in ED is simple, with a few numbers of adverse events. None was severe. Efficiency is correct after 30 to 60 minutes.
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Affiliation(s)
- C Wille
- Département des urgences pédiatriques, hôpital Necker-Enfants-Malades, assistance publique-hôpitaux de Paris,149, rue de Sèvres, 75743 Paris cedex 15, France
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Abstract
This paper is the twenty-fourth installment of the annual review of research concerning the opiate system. It summarizes papers published during 2001 that studied the behavioral effects of the opiate peptides and antagonists. The particular topics covered this year include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology(Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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