Randomized Clinical Trial of Morphine in Acute Abdominal Pain

Montefiore Medical Center, New York, New York, United States
Annals of emergency medicine (Impact Factor: 4.68). 09/2006; 48(2):150-60, 160.e1-4. DOI: 10.1016/j.annemergmed.2005.11.020
Source: PubMed


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.
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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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    • "Children with “surgical” abdomens continued to have persistent tenderness to palpation and percussion. Gallagher and colleagues showed that parenteral analgesia greatly reduced pain score without sacrificing diagnostic accuracy, which was approximately 85% in both the morphine and placebo group.43 In a matched case-control study by Frei and colleagues44 who investigated the association between early use of analgesia and delay in treatment of appendicitis, results showed that in comparing cases and controls for early opiate use (26/103 cases, 24/103 controls), no association was found with delayed treatment (odds ratio, 1.11; P = 0.745; 95% CI, 0.59–3.89). "
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    ABSTRACT: Pain is the most common reason people visit emergency rooms. Pain does not discriminate on the basis of gender, race or age. The state of pain management in the emergency department (ED) is disturbing. ED physicians often do not provide adequate analgesia to their patients, do not meet patients' expectations in treating their pain, and struggle to change their practice regarding analgesia. A review of multiple publications has identified the following causes of poor management of painful conditions in the ED: failure to acknowledge pain, failure to assess initial pain, failure to have pain management guidelines in ED, failure to document pain and to assess treatment adequacy, and failure to meet patient's expectations. The barriers that preclude emergency physicians from proper pain management include ethnic and racial bias, gender bias, age bias, inadequate knowledge and formal training in acute pain management, opiophobia, the ED, and the ED culture. ED physicians must realize that pain is a true emergency and treat it as such.
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