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The recommended dose of intravenous morphine does not control severe acute pain in patients presenting to the emergency department

Intravenous morphine is the standard analgesic to treat severe, acute pain due to burns, extremity fractures, or sickle cell crises seen in the emergency department (ED). However, the recommended weight-based intravenous dose of morphine of 0.1 mg/kg is not effective for controlling severe acute pain in the majority of ED patients, concludes a study supported in part by the Agency for Healthcare Research and Quality (HS13924). Only one-third of ED patients in the study obtained more than 50 percent relief of pain with this dose.

Titration of additional doses of morphine may be necessary for many ED patients in acute pain, conclude Polly E. Bijur, Ph.D., and colleagues at the Albert Einstein College of Medicine. They note that the study dose may be even higher than what is routinely administered in many EDs due to clinicians' concern about the adverse effects of opioids, such as respiratory depression. However, none of the patients in this study had significant adverse effects requiring the administration of an opioid antagonist. Also, individuals vary in their response to opioids. Thus, it should not be surprising that a fixed dose of morphine does not produce adequate analgesia in all patients, notes Dr. Bijur.

The researchers' findings were based on a prospective study of a predominantly poor, inner-city group of 119 Hispanic and black adults who arrived at an academic urban ED with acute, severe pain. Patients rated their pain intensity on a scale ranging from 0 for no pain to 10 for worst possible pain immediately before they received 0.1 mg/kg of intravenous morphine and 30 minutes later. The median numeric rating scale pain score at baseline was 10. Sixty-seven percent of the patients receiving morphine reported a less than 50 percent decrease in pain. Sixteen percent of patients reported no change or an increase in pain in the 30-minute interval.

See "Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients," by Dr. Bijur, Mark K. Kenny, Ph.D., and E. John Gallagher, M.D., in the October 2005 Annals of Emergency Medicine 46(4), pp. 362-367.

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