Analgesics for Abdominal Pain ============================= Attard AR; Corlett MJ; Kidner NJ; Leslie AP; Fraser IA Safety of early pain relief for acute abdominal pain [see comments] BMJ, 305: 6853, 1992 Sep 5, 554-6 OBJECTIVES--(a) to determine the efficacy of papaveretum in treating pain when administered early to patients presenting with acute abdominal pain and (b) to assess its effect on subsequent diagnosis and management. DESIGN--Prospective, randomised, placebo controlled study. SETTING--Walsgrave Hospital, Coventry. SUBJECTS--100 consecutive patients with clinically significant abdominal pain who were admitted as emergencies to a surgical firm. INTERVENTIONS--Intramuscular injection of up to 20 mg papaveretum or an equivalent volume of saline. OUTCOME MEASURES--Pain and tenderness scores, assessment of patient comfort, accuracy of diagnosis, and management decisions. RESULTS--Median pain and tenderness scores were lower after papaveretum (pain score 8.3 in control group and 3.1 in treatment group, p < 0.0001; tenderness score 8.1 in control group and 5.1 in treatment group, p < 0.0001). Forty eight patients were deemed to be comfortable after papaveretum compared with nine after saline. Incorrect diagnoses and management decisions applied to two patients after papaveretum compared with nine patients after saline. CONCLUSION--Early administration of opiate analgesia to patients with acute abdominal pain can greatly reduce their pain. This does not interfere with diagnosis, which may even be facilitated despite a reduction in the severity of physical signs. These patients should not be denied effective treatment. Zoltie N; Cust MP Analgesia in the acute abdomen. Ann R Coll Surg Engl, 68: 4, 1986 Jul, 209-10 In a prospective sequential double blind trial 288 patients with acute abdominal pain were given sublingual buprenorphine 200 mcg, sublingual buprenorphine 400 mcg, or placebo. Pain relief was proportional to the number of tablets administered; buprenorphine had no difference in effect compared to placebo. Physical signs altered in proportion to dosage, but this had no effect on clinical diagnosis. We conclude that patients with acute abdominal pain may be given buprenorphine without fear of masking the diagnosis. Bergentz SE [Analgesics in acute abdominal pain. Categorical prohibition is absurd] Lakartidningen, 90: 34, 1993 Aug 25, 2741-2 Pace et. al. Intavenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain. Acad EM 1996;3:1086-92 Attard, A. R., M. J. Corlett, et al. (1992). "Safety of early pain relief for acute abdominal pain." Bmj 305(6853): 554-6. OBJECTIVES--(a) to determine the efficacy of papaveretum in treating pain when administered early to patients presenting with acute abdominal pain and (b) to assess its effect on subsequent diagnosis and management. DESIGN--Prospective, randomised, placebo controlled study. SETTING--Walsgrave Hospital, Coventry. SUBJECTS--100 consecutive patients with clinically significant abdominal pain who were admitted as emergencies to a surgical firm. INTERVENTIONS--Intramuscular injection of up to 20 mg papaveretum or an equivalent volume of saline. OUTCOME MEASURES--Pain and tenderness scores, assessment of patient comfort, accuracy of diagnosis, and management decisions. RESULTS--Median pain and tenderness scores were lower after papaveretum (pain score 8.3 in control group and 3.1 in treatment group, p < 0.0001; tenderness score 8.1 in control group and 5.1 in treatment group, p < 0.0001). Forty eight patients were deemed to be comfortable after papaveretum compared with nine after saline. Incorrect diagnoses and management decisions applied to two patients after papaveretum compared with nine patients after saline. CONCLUSION--Early administration of opiate analgesia to patients with acute abdominal pain can greatly reduce their pain. This does not interfere with diagnosis, which may even be facilitated despite a reduction in the severity of physical signs. These patients should not be denied effective treatment. Kim, M. K., R. T. Strait, et al. (2002). "A randomized clinical trial of analgesia in children with acute abdominal pain." Acad Emerg Med 9(4): 281-7. OBJECTIVE: To evaluate the effects of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. METHODS: A randomized, double-blind, placebo-controlled clinical trial was conducted at an emergency department of a tertiary care children's hospital. Children aged 5-18 years with abdominal pain of < or =5 days' duration, pain score > or =5 on a 0-10 visual analog scale, and need for surgical evaluation were eligible. Following the initial assessment, patients were randomized to receive either 0.1 mg/kg morphine or an equal volume of saline. The pediatric emergency medicine physician and surgical consultant independently recorded the areas of tenderness to palpation and percussion, and their diagnoses before the study medication and 15 to 30 minutes later. RESULTS: Sixty patients were enrolled, and 29 received morphine and 31 received saline. The demographic characteristics between the two groups were similar. The median reduction of pain score between the two study groups was 2 (95% CI = 1 to 4; p = 0.002). There was no significant change in the areas of tenderness in both study groups. Children with surgical conditions had persistent tenderness to palpation and/or percussion. There was no significant change in the diagnostic accuracy between the study groups and between the physician groups. All patients requiring laparotomy were identified and no significant complication was noted in the morphine group. CONCLUSIONS: Intravenous morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination, and morphine does not affect the ability to identify children with surgical conditions. Mahadevan, M. and L. Graff (2000). "Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain." Am J Emerg Med 18(7): 753-6. Giving an analgesic to patients with right lower quadrant (RLQ) pain causes greater alteration of abdominal signs predictive of appendicitis than placebo. A randomized double-blinded controlled trial of 68 patients who received either tramadol or placebo. Absence or presence of seven abdominal signs (tenderness on light and deep palpation, tenderness in the RLQ and elsewhere, rebound, cough, and percussion tenderness) and pain (100 mm Visual Analog Scale [VAS]) at 0 and 30 minutes were recorded. The predictive value of each physical finding (PF) was measured using an 11-point PF score weighted by likelihood ratios. There was significant reduction in mean VAS of 14.2 mm (95% CI 5.6 to 22.8) in analgesic group versus 6.5 mm (95% CI 1.6 to 11.4) in placebo group. The analgesic group had less normalization of signs as measured by the PF score in all patients [32 of 154 (20.8%) versus 40 of 121 (33.1 %) (P = .031)] and in those with proven appendicitis [4 of 33 (12.1%) versus 10/22 (45.5%) (P = .014)]. Parenteral use of tramadol in emergency department patients with RLQ pain resulted in significant levels of pain reduction without concurrent normalisation of abdominal examination findings indicative of acute appendicitis. McHale, P. M. and F. LoVecchio (2001). "Narcotic analgesia in the acute abdomen--a review of prospective trials." Eur J Emerg Med 8(2): 131-6. Withholding administration of narcotic analgesia in patients with acute abdominal pain for fear of masking pathology is still pervasive in current medical practice. We reviewed all the prospective trials that investigated the safety, adverse affects, and ultimate outcome in patients with acute abdominal pain receiving narcotic analgesia within the emergency department (ED). No adverse outcomes or delays in diagnosis could be attributed to the administration of analgesia. Based on this research, we propose that it is safe and humane to administer narcotic pain relief to patients presenting to the ED with acute abdominal pain provided no contraindications exist. Pace, S. and T. F. Burke (1996). "Intravenous morphine for early pain relief in patients with acute abdominal pain." Acad Emerg Med 3(12): 1086-92. OBJECTIVE: To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain. METHODS: Prospective, double-blind, placebo-controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60,000 visits. Patients > or = 18 years old who had abdominal pain for < or = 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved. RESULTS: Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED; 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 +/- 2.8 cm, than it did for the NS group, 0.8 +/- 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 +/- 0.5 mL vs 1.8 +/- 0.4 mL (p < 0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group. CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients. Thomas, S. H., W. Silen, et al. (2003). "Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial." J Am Coll Surg 196(1): 18-31. BACKGROUND: Because of concerns about masking important physical findings, there is controversy surrounding whether it is safe to provide analgesia to patients with undifferentiated abdominal pain. The purpose of this study was to address the effects of analgesia on the physical examination and diagnostic accuracy for patients with abdominal pain. STUDY DESIGN: The study was a prospective, double-blind clinical trial in which adult Emergency Department (ED) patients with undifferentiated abdominal pain were randomized to receive placebo (control group, n = 36) or morphine sulphate (MS group, n = 38). Diagnostic and physical examination assessments were recorded before and after a 60-minute period during which study medication was titrated. Diagnostic accuracy and physical examination changes were compared between groups using univariate statistical analyses. RESULTS: There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy. The overall likelihood of change in severity of tenderness was similar in MS (37.7%) as compared with control (35.3%) patients (risk ratio [RR] 1.07, 95% confidence interval [CI] 0.64-1.78). MS patients were no more likely than controls to have a change in pain location (34.0% versus 41.2%, RR 0.82, 95% CI 0.50-1.36). Diagnostic accuracy did not differ between MS and control groups (64.2% versus 66.7%, RR 0.96, 95% CI 0.73-1.27). There were no differences between groups with respect to likelihood of any change occurring in the diagnostic list (37.7% versus 31.4%, RR 1.20, 95% CI 0.71-2.05). Correlation with clinical course and final diagnosis revealed no instance of masking of physical examination findings. CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain.