title: Long-acting morphine following hip or knee replacement: a randomized, double-blind, placebo-controlled trial.
abstract: BACKGROUND
  Patients undergoing total hip or knee replacement surgery experience unmanaged pain during postoperative physiotherapy sessions. It was theorized that a baseline opioid would improve pain management.
  
  
  OBJECTIVE
  To examine the effectiveness of adding long-acting oral morphine to a routine postoperative regimen for total hip or knee replacement surgery.
  
  
  METHODS
  The present study was a double-blind, randomized, placebo-controlled trial for patients undergoing total hip or knee replacement surgery. All patients received routine postoperative analgesia; in addition, the treatment group received long-acting oral morphine 30 mg orally twice daily for three days, while the control group received placebo capsules. The primary end point was a decrease in pain scores by two points on a 0- to 10-point pain rating scale. Secondary end points included adverse effects, acute confusion, pain-related interferences in function and sleep, length of stay and patient satisfaction.
  
  
  RESULTS
  Two hundred patients were enrolled in the present study (March 2004 to March 2006). Although the groups were large enough to yield statistical significance, most pain scores did not reach the predetermined improvement for clinical significance. Additionally, there was an increase in opioid usage (P<0.0001), vomiting (P=0.0148) and oversedation (P=0.08). There were no statistically significant changes in function or sleep. Improved satisfaction with pain management was minimal (P=0.052).
  
  
  CONCLUSIONS
  The present study was undertaken to determine the value of adding a long-acting opioid (morphine) to the usual care of patients undergoing total hip or total knee replacement surgery. The results yielded minimally improved pain scores and additional adverse effects (vomiting and oversedation). Published research in which long-acting opioids (oxycodone) were used for similar postoperative procedures did not robustly report improved pain scores. In addition, patients using a long-acting opioid (oxycodone) during the postoperative period reported somnolence, dizziness and confusion. Statistically, the patients in the present study showed higher confusion scores and no improvement for pain-related interferences with activity or walking. The treatment group did report increased satisfaction; however, the significance was weak.
  
  
  CONCLUSIONS
  Thirty milligrams twice per day of long-acting morphine from days 1 to 3 following total hip and total knee replacement surgery provided minimal improvements in pain scores, and more adverse effects in the treatment group. The overall strength of evidence for improved outcomes is minimal and thus not supported.
authors.affiliation: Department of Nursing, Acute Pain Service, The Scarborough Hospital, Toronto, Ontario. shirley.musclow@utoronto.ca
authors.forename: Shirley Lynn
authors.initials: SL
authors.lastname: Musclow
authors.forename: Tabatha
authors.initials: T
authors.lastname: Bowers
authors.forename: Hanna
authors.initials: H
authors.lastname: Vo
authors.forename: Mark
authors.initials: M
authors.lastname: Glube
authors.forename: Thong
authors.initials: T
authors.lastname: Nguyen
mesh_terms: D000208:Acute Disease; D000284:Administration, Oral; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage* / Q000009:adverse effects; D010149:Postoperative Pain / Q000188:drug therapy*; D017060:Patient Satisfaction; D010919:Placebos; D012890:Sleep / Q000187:drug effects
chemical_list: D000701:Analgesics, Opioid; D010919:Placebos; D009020:Morphine