Ibuprofen appears to be as effective as oral morphine for reducing mild to moderate pain in children who have had orthopedic day surgery – without the side-effects associated with the opioid, a study has found.
Principal investigator Dr. Naveen Poonai, a pediatric emergency medicine specialist at Western University, said the researchers wanted to compare the efficacy of both medications for two reasons:
"We are going through an opioid epidemic in Canada and if we can try our best to provide the best evidence for when we should use opioids and when we shouldn't in children, that might allow us to do our part to decrease the risks to children with respect to exposure to opioids," Poonai said Tuesday from London, Ont.
"The second reason is we know that in children pain post-operatively is not well-managed."
The study, published Tuesday in the Canadian Medical Association Journal, enrolled 154 children aged five to 17, who had undergone minor orthopedic procedures, such as fracture stabilization, removal of pins in bones, and arthroscopy of the knee. Most of the procedures were related to sports injuries.
Half the children were randomized to receive liquid ibuprofen, while the other half were prescribed liquid morphine for two days, to be administered at home.
"What we found was that in children with mild to moderate pain post-operatively, (those) who received ... oral morphine or ibuprofen experienced comparable levels of pain relief for the first 48 hours," said Poonai, noting that pain levels typically begin to diminish after that point.
"However, oral morphine was associated with more side-effects than ibuprofen, so we concluded that ibuprofen was a better analgesic option in that population," he said.
Side-effects from the opioid included drowsiness, nausea and vomiting, as well as a higher rate of constipation in some children.
However, Poonai said neither ibuprofen nor morphine fully eliminated the pain. Children, who indicated an average post-surgery pain level of three on a scale of one to 10, said their discomfort after taking the drugs dropped to a one or two on the scale after each dose.
He said further study would be needed to see if the results would hold true for mild to moderate pain caused by other types of surgery.
Dr. Fiona Campbell, a specialist in the department of anesthesia and pain medicine at Sick Kids Hospital in Toronto, agreed with the conclusion that ibuprofen is a safer medication for children due to the adverse effects of morphine.
But she cautioned that people shouldn't conclude from these findings that morphine will not be needed for pain control after operations that generate more significant pain, such as repairing a major bone fracture with pins or nails or abdominal surgery.
"So I think what's important is to understand the context of the population they did this study on," said Campbell, who was not involved in the research.
The study also showed that even children in the "mild" range had enough residual pain to require the addition of acetaminophen as a "break-through" medication, she said.
"At Sick Kids when we discharge patients from hospital or even patients who are in hospital, we like to use a balanced multi-modal approach to pain management, by which I mean we use not only medication but also physical and psychological strategies."
Those include comfortable positioning and the use of ice as an anti-inflammatory, as well as psychological distraction, such as watching a movie on TV, playing an online game or being read to by a parent or caregiver.
"Those things dial down pain scores as well."
While such strategies can help minimize opioid use, drugs like morphine need to remain available for when they are needed, Campbell said, adding that with the opioid crisis, some people are trying to get rid of the potent medications.
"But we run the risk of throwing the baby out with the bath water because pain management and comfort is so important, not just for the suffering involved but also because if you don't treat pain properly, it can become chronic."