Ideal pain relief for musculoskeletal injury remains elusive

A comparison of a combination of oral morphine and oral ibuprofen with each of these drugs alone found that none of these options provided optimal analgesia for the pain of a musculoskeletal injury (MSK-I). A Canadian study was conducted in 456 children aged between 6 and 17 years who visited a pediatric emergency department (ED) with an MSK-1, most often to the ankle, wrist, or knee, with a pain score of >29 mm on the visual analog scale (VAS) of 0 to 100 mm.

Participants were assigned to 1 of 3 treatment groups: morphine plus ibuprofen; morphine plus placebo of ibuprofen; or ibuprofen plus placebo of morphine. The VAS scores were collected when the study medication was administered and 30, 60, 90, and 120 minutes later.

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At 60 minutes after the medication was administered (the time of peak action for both oral morphine and ibuprofen), pain score reduction was similar in all 3 groups; a VAS pain score <30 mm, indicating mild pain, was achieved by 30% of the morphine-plus-ibuprofen group, 29% of the morphine group, and 33% of the ibuprofen group. Although children in the morphine plus ibuprofen group and in the morphine group experienced more adverse effects than those in the ibuprofen group, no participant had a serious adverse event (Le May S, et al. Pediatrics. 2017;140[5]:e20170186).

THOUGHTS FROM DR. BURKE

The pendulum has swung. Fifteen years ago, we began to focus on pain as a “vital sign” and moved aggressively to treat pain in all settings. An epidemic of opioid addiction has caused us to look again at how we manage pain, rethinking the role of opioids. In this study, neither oral morphine nor morphine and ibuprofen together offered superior pain reduction to ibuprofen alone, and none of the 3 approaches was particularly effective. Perhaps it is time to look again at nonmedical management of pain. We can look to our colleagues who are child life specialists to lead the way.