Post-op pain management for kids: Hold the morphine

Clinical Brief – October, 12th

The Brief

To manage pain after a kid gets surgery for something like implant removal or joint repair, would you pick morphine or a non-prescription painkiller?

A Canadian trial reported that over-the-counter painkillers may manage pain after an orthopedic surgery just as well as morphine, but comes with fewer side effects.

What’s orthopedic surgery?

Orthopedic surgery covers operations on the bones, joints, ligaments, muscles, nerves, and tendons. According to researchers who ran this trial, “moderate to severe pain is the most common post-op complaint”.

Now, recovery and post-op pain management is often dealt with at home instead of in a hospital because it’s estimated that more than 80% of pediatric surgeries are performed as outpatients. It also doesn’t help that orthopedic procedures are said to be associated with the highest incidence of post-discharge pain.

Given the choice, should we use oral morphine or a non-prescription painkiller to manage post-op pain?

Risk of opioid abuse

It’s been reported that when a child takes prescription opioids before they graduate from high school, their risk of future opioid misuse after high school is increased by 33% – even when it’s taken for legitimate reasons.

But what if we can spare the opioid without sacrificing pain control?

The study

Researchers from the London Health Sciences Centre, Canada, recruited about 150 kids between 5 and 17 years old. Everyone had minor orthopedic surgery. Nearly 4 out of 5 procedures were for implant removal, various joint repairs or keyhole surgery.

After their surgeries, the kids were randomized 50/50 to get either morphine pills or ibuprofen (Advil, Motrin, and according to the Mayo Clinic, many others). The treatments were carefully masked so neither the kids nor their caregivers or healthcare team knew what they were taking.

To keep things properly blinded, everyone took their pills every 6 hours. If the pain was unbearable, they could take an additional dose of acetaminophen (aka paracetamol, Tylenol, etc.).

When researchers asked the kids to rate their post-op pain before and after taking their pain meds, they found that both morphine and ibuprofen managed to reduce pain after the first dose. Surprisingly, the degree of pain reduction was statistically identical.

The same results repeated itself after the second dose, third dose, and all the way after the eighth and final dose of either morphine or ibuprofen.

The safety profile, however, was significantly better with ibuprofen. Overall, 39% of kids taking ibuprofen reported side effects of any kind vs 69% for morphine, nearly double. The most common side effects were nausea, vomiting, drowsiness, and dizziness. All of these side effects were significantly more common with morphine than with ibuprofen.

Bottom line

This was a small but well-designed study that showed ibuprofen plus acetaminophen taken as needed can be equally effective as morphine, with significantly fewer side effects…

“…which suggests that ibuprofen is a better first-line option after minor surgery.”

– Poonai N, et al.

For more studies check out my Twitter feed 🤓.

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