Adding Codeine Doesn't Increase Pain Relief in Limb Trauma

October 2010 

By Hillel Kuttler
Elsevier Global Medical News

BALTIMORE - Codeine combined with ibuprofen did not relieve pain from pediatric acute musculoskeletal injuries any more effectively than did ibuprofen alone, according to findings from a small randomized, controlled trial.

The take-home message is that pain management in children generally tends to be poor, and that those presenting with a limb trauma most likely need to receive an opioid, and possibly one that's stronger than codeine, "to better relieve their pain and bring it down to below [a Visual Analog Score of] 4," Sylvie Le May, Ph.D., said at the annual meeting of the American Pain Society.

The study involved 83 children aged 6-17 years who presented to the emergency department at CHU Sainte-Justine University Hospital Center, Montreal, with limb fractures, sprains, and contusions, between March 2008 and October 2009.

At baseline, the children reported having moderate to severe pain (4-10 on the VAS pain scale). A total of 42 patients were randomized to receive codeine and ibuprofen, while 41 patients in the control group received ibuprofen and placebo.

The children's pain levels were measured at triage, then at the 60-, 90-, and 120-minute marks afterward. Children in the experimental group had a mean score of 5.9 VAS at triage, then 4.2, 4.0, and 3.5, respectively; those in the control group had mean scores of 5.7, 3.9, 4.1, and 3.8.

Dr. Le May explained that she undertook the study because, in her experience as a nurse, children "with this kind of pain [from] limb trauma should receive an opioid. That's the standard, but physicians are not following the standard."

She added that she had not expected a weak opioid such as codeine to be effective in the study.

While other researchers have studied the pain relief effectiveness of analgesics, comparisons have not been made involving combinations of analgesics, she said. In addition, in one such study, 46% of adults - but just 26% of children - coming to the ED with fractures received an opioid to manage their pain, said the Sainte-Justine researcher and associate professor at the University of Montreal's school of nursing.

Dr. Le May said that her 2005-2007 study of 150 charts of children presenting to EDs with severe sprains, fractures, burns, deep lacerations, and abdominal pain found that only 3% of children received an opioid for their pain. That is likely due to a lack of knowledge about pain management, especially in pediatrics, she noted.

In a forthcoming study, Dr. Le May will test the effectiveness of ibuprofen used in combination with oxycodone.

She reported having no conflicts of interest.

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