Original ContributionIntravenous morphine titration to treat severe pain in the ED☆,☆☆,★
Introduction
Acute pain relief is now a standard requirement of effective clinical practice in the ED [1]. However, despite important progress in pain management, undertreatment of pain in the ED remains an unresolved and major problem [2], [3], [4]. Intravenous administration of opioids is widely used for acute pain relief in the immediate postoperative period and use of small intravenous boluses of morphine (intravenous morphine titration) allows a rapid titration of the dose needed for complete pain relief [5], [7]. However, several barriers have prevented its application in the ED including, high admission numbers, inadequate training in pain relief, lack of continuity of care, and concern about opioid adverse effects, not to mention concerns that have been repeatedly refuted such as fear of psychological addiction or impairment of clinical diagnostic accuracy [8]. The main consequence is that even the most recent clinical trials have investigated therapeutic options that would have been considered as unacceptable in other settings [9], [10]. In contrast, intravenous morphine titration has been recently advocated for acute cancer pain control, suggesting that this technique can also be applied outside the post-anesthesia care unit [11], [12]. Moreover, although the safety of the technique has not been assessed in the emergency setting, intravenous morphine titration is now used on a routine basis in some ED [13].
Therefore, the goal of our study was to test the hypothesis that intravenous morphine titration is an efficient and safe means of obtaining complete and rapid pain relief in the ED. We used a protocol for adult patients, which has been demonstrated to be efficacious, safe, and simple to perform for nurses in the postoperative period [5], [6], [7].
Section snippets
Material and methods
We used an observational prospective cohort design. The study protocol was approved by our institutional review board (Comité de Protection des Personnes se Prêtant à la Recherche Biomédicale Pitié-Salpêtrière, Paris, France). Because the protocol was considered as routine care applied to all patients, authorization to waive written informed consent was granted.
Results
A total of 625 consecutive patients were included in the study. Important data were lacking in 4 patients, and, thus, 621 patients were considered for analysis.
There were 340 (55%) men and 281 (45%) women, the mean age was 42 ± 16 years (extremes, 18-106), and the mean weight was 71 ± 15 kg. The cause of pain was traumatic in 114 (18%) patients and nontraumatic in 507 (82%) patients. The location of pain in nontraumatic causes was the spine (n = 165, 27%), abdomen and pelvis (n = 239, 38%),
Discussion
In the present study, we demonstrated that intravenous morphine titration can be safely used in the emergency setting to treat acute severe pain, with an incidence of morphine-related adverse effects of 11% and an incidence of severe respiratory adverse effects of 0 (95% CI, <0.6%). Complete pain relief was obtained in 82% of our patients, the efficacy reaching 99% in patients in whom the titration process could be completed.
An outstanding feature of the clinical use of opioids is the
Limitations
Some remarks must be included to assess the limitations of our study. First, the use of VAS assumes that pain is a unidimensional experience. Although intensity is a very important dimension of pain, it is clear that pain refers to a variety of sensations that cannot be categorized under a single linguistic label which varies only in intensity [22]. Nevertheless, it should be pointed out that VAS has been widely accepted because of its ease and brevity of administration, its minimal
Conclusion
Intravenous morphine titration may be a simple and efficacious option to avoid undertreatment of acute severe pain in the emergency setting, given a strict protocol, close clinical monitoring, and appropriate training of the staff. Poor compliance with titration protocol is associated with a greater rate of inadequate pain relief.
Acknowledgment
We thank the nurses and the emergency physicians of the ED of CHU Pitié-Salpêtrière, Paris, France for their work on this study and Dr DJ Baker, DM, FRCA (Department of Anesthesiology, CHU Necker-Enfants Malades, Paris) for reviewing the manuscript. The study was supported by a research grant from the Fondation Hôpitaux de Paris-Hôpitaux de France.
References (28)
- et al.
Emergency department analgesia for fracture pain
Ann Emerg Med
(2003) Emergency medicine and pain: a topography of influence
Ann Emerg Med
(2004)- et al.
Inadequate analgesia in emergency medicine
Ann Emerg Med
(2004) - et al.
Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients
Ann Emerg Med
(2005) Measurement of pain
Lancet
(1974)- et al.
Is morphine-induced sedation synonymous with analgesia during intravenous morphine titration?
Br J Anaesth
(2002) - et al.
Adjunctive analgesia with intravenous propacetamol does not reduce morphine-related adverse effects
Br J Anaesth
(2003) - et al.
Effects of a loading dose of morphine before intravenous morphine titration for postoperative pain relief. A randomized, double blind, placebo-control study
Br J Anaesth
(2007) - et al.
Age as a risk factor for inadequate emergency department analgesia
Am J Emerg Med
(1996) Clinical effectiveness standard 3: pain
Postoperative titration of intravenous morphine
Eur J Anaesthesiol
Relationship between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration
Anesthesiology
Sex-and age-related in morphine requirements for postoperative pain relief
Anesthesiology
Randomized clinical trial of morphine in acute abdominal pain
Ann Emerg Med
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Authors' contributions: Virginie Lvovschi took part in data acquisition and verification, interpretation of the results, emergency physician training, and drafting of the manuscript. Frédéric Aubrun took part in the study conception and interpretation of the results. Pascale Bonnet and Mouhssine Bendahou took part in data acquisition and emergency physician training. Anna Bouchara took part in data acquisition and verification, and interpretation of the results. Béatrice Humbert took part in nurse training and administrative support. Pierre Hausfater took part in interpretation of the results and revision of the manuscript. Bruno Riou took part in study conception, statistical analysis, interpretation of the results, and drafting of the manuscript. All authors contributed to the final version of the manuscript.
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Conflict of interest: We declare that we have no conflict of interest related to this work. The funding source had no role in the study conception and manuscript writing.
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Sources of support: The study was supported by a research grant from Fondation des Hôpitaux de France. Other support was provided solely by institutional sources.