Randomized clinical trial of morphine in acute abdominal pain

Montefiore Medical Center, New York, New York, United States
Annals of emergency medicine (Impact Factor: 4.33). 09/2006; 48(2):150-60, 160.e1-4. DOI: 10.1016/j.annemergmed.2005.11.020
Source: PubMed

ABSTRACT Administration of analgesia to patients with acute abdominal pain is controversial. We test the hypothesis that morphine given to emergency department (ED) patients with acute abdominal pain will reduce discomfort and improve clinically important diagnostic accuracy.
Pain was measured with a standard 0- to 100-mm visual analog scale. ED patients with acute abdominal pain were randomized in a double-blind fashion to 0.1 mg/kg intravenous morphine or placebo. The primary endpoint was the difference between the 2 study arms in clinically important diagnostic accuracy. Clinically important diagnostic accuracy was defined a priori by its complement, clinically important diagnostic error, using 2 independent, blinded investigators to identify any discordance between the provisional and final diagnoses that might adversely affect the patient's health status. The provisional diagnosis was provided by an ED attending physician, who examined the patient only once, 15 minutes after administration of the study agent. The final diagnosis was obtained through follow-up at least 6 weeks after the index ED visit.
We randomized 160 patients, of whom 153 patients were available for analysis, 78 patients in the morphine group and 75 patients in the placebo group. Baseline features were similar in both groups, including initial median visual analog scale scores of 98 mm and 99 mm. The median decrease in visual analog scale score at 15 minutes was 33 mm in the morphine group and 2 mm in the placebo group. There were 11 instances of diagnostic discordance in each group, for a clinically important diagnostic accuracy of 86% (67/78) in the morphine group and 85% (64/75) in the placebo group. The difference in clinically important diagnostic accuracy between the 2 groups was 1% (95% confidence interval [CI] -11% to 12%). Analysis by efficacy and intention to treat yielded similar results. Kappa for interobserver concordance in classification of clinically important diagnostic accuracy was 0.94 (95% CI 0.79 to 1.00). No patients required naloxone.
Although administration of intravenous morphine to adult ED patients with acute abdominal pain could lead to as much as a 12% difference in diagnostic accuracy, equally favoring opioid or placebo, our data are most consistent with the inference that morphine safely provides analgesia without impairing clinically important diagnostic accuracy.

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Available from: EDWARD JOHN Gallagher, Aug 14, 2014
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    • "In contrast to the described beliefs and fears, the published evidence-based literature supports prediagnostic administration of analgesia in the setting of acute abdominal pain. Several studies (Attard et al., 1992; Pace and Burke, 1996; LoVecchio et al., 1997; Vermeulen et al., 1999; Mahadevan and Graff, 2000; Thomas et al., 2003; Gallagher et al., 2006; Amoli et al., 2008) and one Cochrane review published in 2007 (Manterola et al., 2007), which was updated in 2011 (Manterola et al., 2011), have demonstrated that administering analgesia for acute abdominal pain is appropriate prior to the diagnosis regardless of the aetiology of the abdominal pain. The authors of the Cochrane review concluded that the use of opioid analgesics neither increased the risk of misdiagnosis nor increased the risk of incorrect treatment decisions being made; the Cochrane reviewers furthermore stated that pain therapy may, in fact, make the clinical examination easier in patients with an acute abdomen. "
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    ABSTRACT: Appropriate pain therapy prior to diagnosis in patients with acute abdominal pain remains controversial. Several recent studies have demonstrated that pain therapy does not negatively influence either the diagnosis or subsequent treatment of these patients; however, current practice patterns continue to favour withholding pain medication prior to diagnosis and surgical treatment decision. A systematic review of PubMed, Web-of-Science and The-Cochrane-Library from 1929 to 2011 was carried out using the key words of 'acute', 'abdomen', 'pain', 'emergency' as well as different pain drugs in use, revealed 84 papers. The results of the literature review were incorporated into six sections to describe management of acute abdominal pain: (1) Physiology of Pain; (2) Common Aetiologies of Abdominal Pain; (3) Pre-diagnostic Analgesia; (4) Pain Therapy for Acute Abdominal Pain; (5) Analgesia for Acute Abdominal Pain in Special Patient Populations; and (6) Ethical and Medico-legal Considerations in Current Analgesia Practices. A comprehensive algorithm for analgesia for acute abdominal pain in the general adult population was developed. A review of the literature of common aetiologies and management of acute abdominal pain in the general adult population and special patient populations seen in the emergency room revealed that intravenous administration of paracetamol, dipyrone or piritramide are currently the analgesics of choice in this clinical setting. Combinations of non-opioids and opioids should be administered in patients with moderate, severe or extreme pain, adjusting the treatment on the basis of repeated pain assessment, which improves overall pain management.
    European journal of pain (London, England) 08/2014; 18(7). DOI:10.1002/j.1532-2149.2014.00456.x · 3.22 Impact Factor
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    • "By tradition, analgesic in the emergency department has been limited, to avoid negative effects on the diagnosis process or the further treatment (Thomas et al., 2003; Neighbor et al., 2004). Several recent studies (Thomas et al., 2003; Gallagher et al., 2006; Amoli et al., 2008) have shown that it is safe to give analgesic to patients with abdominal pain and that it does not delay diagnosis. A policy for pain management might facilitate the possibilities of giving adequate analgesic and pain relief (Marinsek et al., 2007). "
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    ABSTRACT: Abdominal pain is one of the most frequent reasons for seeking care in an emergency department. Surveys have shown that patients are not satisfied with the pain management they receive. Reasons for giving inadequate pain management may include poor knowledge about pain assessment, myths concerning pain, lack of communication between the patient and healthcare professional, and organizational limitations. The aim of the study was to investigate the outcome of nursing assessment, pain assessment and nurse-initiated intravenous opioid analgesic compared to standard procedure for patients seeking emergency care for abdominal pain. Outcome measures were: (a) pain intensity, (b) frequency of received analgesic, (c) time to analgesic, (d) transit time, and (e) patients' perceptions of the quality of care in pain management. A quasi-experimental design with ABA phases was used. The study was conducted in an emergency department at a Swedish university hospital. Patients with abdominal pain seeking care in the emergency department were invited to participate. A total of 50, 100 and 50 patients, respectively, were included for the three phases of the study. The inclusion criteria were: ongoing abdominal pain not lasting for more than 2 days, ≥18 years of age and oriented to person, place and time. Exclusion criteria were: abdominal pain due to trauma, in need of immediate care and pain intensity scored as 9-10. The patients' perceptions of the quality of care in pain management in the emergency department were evaluated by means of a patient questionnaire carried out in the three study phases. The intervention phase included education, nursing assessment protocol and a range order for analgesic. The nursing assessment and the nurse-initiated intravenous opioid analgesic resulted in significant improvement in frequency of receiving analgesic and a reduction in time to analgesic. Patients perceived lower pain intensity and improved quality of care in pain management. The intervention improved the pain management in the emergency department. A structured nursing assessment could also affect the patients' perceptions of the quality of care in pain management in the emergency department.
    International journal of nursing studies 01/2011; 48(1):13-23. DOI:10.1016/j.ijnurstu.2010.06.003 · 2.25 Impact Factor
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    • "Plusieurs publications confirment que l'utilisation de la morphine dans le contexte d'abdomen chirurgical soulage le patient sans générer ni de retard ni de faux diagnostic [54] [65]. Ces deux études viennent donc conforter d'autres études antérieures bien menées en double insu randomisées et prospectives qui concluaient contre placebo à l'absence d'erreur diagnostique liée à l'utilisation de la morphine. "
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    ABSTRACT: A questionnaire was posted on the SFMU website from February 15 through April 15 2007 in order to assess the impact of the 1993 Consensus Conference. Four hundred and seventy-three questionnaires were available for study. Among the main findings, it was noted that most of the emergency physicians had a mixed activity, with a predominance of the adult population. Numeric and analogue scales were widely used. Dolopus and the Edin scale were not employed. Sixty-two percent of persons interrogated used the unit protocol. Seventy-two percent of the interrogated persons had an initial dose of morphine then titration with repeated boluses. Management of adults with pain thus appears to be in compliance with the guidelines. An analysis of the literature, using Medline, Cochrane and ScienceDirect® was based on decreasing level of proof. As for the preceding updates, the articles were classified as follows: randomized controlled studies, practical guidelines, meta-analysis, review articles. Data concerning medication used in the emergency setting for pain relief were selected.
    Douleurs Evaluation - Diagnostic - Traitement 10/2008; 9(5):248-278. DOI:10.1016/j.douler.2008.06.010
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