Research with other addictive substances, e.g., tobacco, alcohol, and marijuana, finds that the earlier in life a child uses an addictive substance, the more likely the child is to become addicted and the more severe the addiction is likely to become.  It is almost certain that the same is true for narcotics.  It is extremely unethical to needlessly expose a child needlessly to highly addictive narcotics, and yet it is done all the time without the parent even knowing.  

Many doctors use highly addictive narcotics on children in childbirth and surgery, yet parents are either never offered an alternative or never even informed that their child is going to receive a highly addictive narcotic!  This is outrageous and should be criminal.  Parents are not told that narcotics are inferior pain relievers; parents are not offered alternatives.  Parents are almost always simply told what the doctors are going to do and given no option but to sign an uninformed consent.

There is not a single study anywhere which I have been able to find that shows that a narcotic is ever superior to a non-narcotic alternative.  In the studies below in which a narcotic is compared to a non-narcotic for surgery on children, the narcotics' track record is 0 wins, 12 loses, and 8 ties.  Narcotics are losers!

Cardiac Cath in Children: Ketamine/Midazolam Better than Meperidine Combination: An IM combination of meperidine, promethazine, and chlorpromazine (DPT) has been given as sedation for pediatric procedures for more than 40 years. In a DB study of 51 children congenital heart disease having cardiac catheterization, oral (PO) ketamine/midazolam was much better tolerated than the narcotic combination (P < 0.0005), had more rapid onset (P < 0.001), and provided much superior sedation (P < 0.005). Respiratory rate decreased after IM DPT only. Heart rate and shortening fraction were stable. Oxygen saturation and mean blood pressure decreased minimally in both groups. Supplemental propofol was more frequently required (P < or = 0.02) and in larger doses (P < 0.05) after IM DPT. Parental satisfaction ratings were higher (P < 0.005) and amnesia was more reliably obtained (P = 0.007) with PO ketamine/midazolam. Two patients needed airway support after the PO medication, as did two other patients when PO ketamine/midazolam was supplemented with IV propofol. Although PO ketamine/midazolam provided superior sedation and amnesia compared to IM DPT, this regimen may require the supervision of an anesthesiologist for safe use. Oral ketamine/midazolam is superior to intramuscular meperidine, promethazine, and chlorpromazine for pediatric cardiac catheterization. Auden SM, et al. University of Louisville and Kosair Children's Hospital. . Anesth Analg 2000 Feb;90(2):299-305.

Child Birth: Meperidine No Better than Placebo for Delivery Pain, But More Side-Effects: In a DB study of 84 women in delivery, there were no statistically significant differences in pain between meperidine and normal saline. Sedative scores, nausea/vomiting and dizziness were significantly worse with meperidine. However, opinion on the effectiveness of pain relief during labor was only 24% in the meperidine group, although it was significantly worse with placebo (7%). Effectiveness of intravenous meperidine for pain relief in the first stage of labour. Soontrapa S, et al. Khon Kaen University, Thailand. J Med Assoc Thai 2002 Nov;85(11):1169-75. Ed: It is virtually certain that using a real pain medication and not a narcotic would have resulted in less pain, fewer side-effects, and lowered the addictive programming of other the mothers and their newborns. One study has shown that children exposed to narcotics during delivery were more likely to develop narcotic programs in adulthood.

Child Birth: Narcotics Ineffective and Unethical; Negative Effects on Newborns: In a DB study of 10 healthy nulliparous women in active labour, even after repeated doses (up to 0.15 mg/kg body weight morphine and up to 1.5 mg/kg body weight meperidine) the findings were uniform, with very high pain scores maintained in each group as assessed with visual analogue scale. The parturients were all significantly sedated and several fell asleep but were awakened by pain during contractions. It was concluded that labor pain is not sensitive to systemically administered morphine or pethidine. These drugs only cause heavy sedation. Authors state, " It therefore seems unethical and medically incorrect to meet parturients' requests for pain relief by giving them sedation. Considering the well documented negative effects on newborn infants we also believe systemic meperidine should be avoided in labor." Lack of analgesic effect of systemically administered morphine or pethidine on labour pain. Olofsson C, et al. Karolinska Hospital, Stockholm, Sweden. Br J Obstet Gynec 1996 Oct;103(10):968-72. 

Dental Extraction Surgery: Sufentanil No Better than Non-Narcotic Ketamine: In a DB study of 50 children ages 5-7 having 6 or more teeth extracted, intranasal sufentanil and intranasal midazolam before anesthesia did no better for ease of administration, speed of onset, degree of sedation, or postoperative analgesia, when compared with intranasal ketamine and intranasal midazolams. Intranasal sufentanil/midazolam versus ketamine/midazolam for analgesia/sedation in the pediatric population prior to undergoing multiple dental extractions under general anesthesia: a prospective, double-blind, randomized comparison. Roelofse JA, et al. University of Stellenbosch. Anest Prog 2004;51(4):114-21.

Dental Pain: Meperidine (Demerol) No Added Value to Dental Procedures with Midazolam: In a DB crossover study of 20 children having dental restorative care, midazolam alone 1 mg/kg did as well as midazolam plus meperidine (0.5 and 1 mg/kg, respectively). All sedative agents were administered orally, and all sedations included 50% nitrous oxide administered via a nasal hood. Researchers concluded, "Oral midazolam alone is just as effective as midazolam with meperidine." Comparison of the efficacy of oral midazolam alone versus midazolam and meperidine in the pediatric dental patient. Musial KM, et al. United States Air Force, Lakenheath, England. Pediatr Dent 2003 Sep-Oct;25(5):468-74. Ed: This is not actually a comparaison study, because meperidine is being compared to a placebo. Numerous medications have done better than narcotics in the larger number of dental studies done with adults.

Ear Surgery: Butorphanol (Stadol) Inferior to Ketoprofen But Better than Acetaminophen with Codeine: In a DB study of 120 children undergoing bilateral myringotomy and tube placement plain acetaminophen 10 mg/kg orally, was compared to acetaminophen 10 mg/kg with 1 mg/kg of codeine orally, transnasal butorphanol 25 micro g/kg given immediately after the induction of anesthesia, and ketorolac 1 mg/kg given IM immediately after the induction of anesthesia. All children received oral midazolam before surgery. IM ketorolac did best. Time to first rescue analgesic was longest in the ketorolac group, and there was no associated postoperative vomiting or nausea. Butorphanol provided superior analgesia when compared with acetaminophen with codeine or plain acetaminophen. Children who received ketorolac versus butorphanol had less vomiting in the 24 h after surgery. Postoperative analgesia in children undergoing myringotomy and placement equalization tubes in ambulatory surgery. Pappas AL, et al. Loyola University. . Anesth Analg 2003 Jun;96(6):1621-4.

Eye Surgery: Ketorolac Just as Good as Meperidine with Much Less Nausea and Vomiting: In a DB study of 52 children having strabismus surgery, IV ketorolac 0.9 mg/kg was as effective as IV meperidine 0.5 mg/kg Recovery scores, Objective Pain Scores and postoperative analgesic requirement were similar in both groups. However, post-op nausea and vomiting were much more frequent with meperidine (P < 0.001) Comparative effects of intravenous ketorolac and pethidine on perioperative analgesia and postoperative nausea and vomiting (PONV) for paediatric strabismus surgery. Shende D, et al. New Delhi, India. Acta Anesth Scand 1999 Mar;43(3):265-9.

Eye Surgery: Ketoprofen Better than Meperidine Which Did No Better than Placebo: In a DB PC study of 91 children undergoing squint opthalmic surgery at King Abdel-Aziz University Hospital Riyadh, preoperative ketoprofen 1 mg/kg, meperidine 1 mg/kg or saline were given. Ketoprofen had lower post-operative pain scores and required less frequent analgesic therapy in the early postoperative period than meperidine. There were no differences in pain scores or analgesic requirements between pethidine and placebo. Analgesic effects of intra-muscular ketoprofen (Profenid) and pethidine for squint surgery in children. Alam K, et al. King Abdel-Aziz University Hospital, Riyadh. Middle East J Anesth 1999 Feb;15(1):31-8.

General Surgery: Ketorolac as Good as Meperidine Relieving Pain: In a DB PC study of 90 children having elective general surgery, orthopedic, or G-U procedures, ketorolac 0.75 mg/kg did as well as meperidine 1 mg/kg in relieving pain and both did better than placebo. Time to first rescue medication, total opioid requirement, pain scores, incidence of vomiting and length of stay were evaluated. Ketorolac and meperidine did not differ with regard to time until first rescue, cumulative proportion requiring rescue, or the number of rescue doses required. A single dose of IM ketorolac prolonged bleeding time by 53 seconds. Effect of ketorolac on bleeding time and postoperative pain in children: a double-blind, placebo-controlled comparison with meperidine. Bean-Lijewski JD, et al. Temple, TX. Clin Anesth 1996 Feb;8(1):25-30.

Hypospadias Surgery: Alfentanil Inferior to Ketamine and No Value as Add-On Either: In a DB study of 109 boys ages 1-9 undergoing hypospadias repair, single dose alfentanil (20 microg/kg) given caudally was not as good as a single dose of ketamine (0.5 mg/kg) alone for pain relief and sedation with alfentanil requiring more and earlier additional analgesia with paracetanol 15 mg/kg (p<0.001 and p=0.009).  Adding alfentanil to ketamine did not improve the benefits of ketamine alone. The comparison of caudal ketamine, alfentanil and ketamine plus alfentanil administration for postoperative analgesia in children. Ozbek H, et al. Cukurova University, Adana, Turkey. . Pediatr Anesth 2002 Sep;12(7):610-6.

Myringotomy and Tube Placement: Ketorolac Better Pain Relief than Butorphanol or Acetaminophen with Codiene: In a DB study of 120 children undergoing bilateral myringotomy and tube placement, IM ketorolac 1 mg/kg had the longest time to first rescue analgesic, and there was no associated postoperative vomiting or nausea. It was followed in effectiveness by transnasal butorphanol 25 mcg.  Both were superior to plain acetaminophen 10 mg/kg orally, and to acetaminophen 10 mg/kg with 1 mg/kg of codeine orally. All children received oral midazolam (0.6 mg/kg) before surgery. Children who received ketorolac versus butorphanol had less vomiting in the 24 h after surgery. Postoperative analgesia in children undergoing myringotomy and placement equalization tubes in ambulatory surgery. Pappas AL, et al. Loyola University Medical Center, Illinois. . Anesth Analg. 2003 Jun;96(6):1621-4

Myringotomy: Acetaminophen/Codeine/Promethazine More Side-effects and No Added Benefit vs. Acteminophen Alone: In a DB study of 95 children ages 1-12 undergoing myringotomy tube insertion surgery, Painstop containing acetaminophen 12 mg, codeine 0.5 mg and promethazine 0.65 mg per 1.0 ml, dosage 1.0 ml/kg caused times to eye opening (P = 0.05) and first oral intake (P = 0.006) to be significantly longer than acetaminophen 20 mg/kg alone. There was, however, no difference in times to discharge. Late sedation was more common in the Painstop group (P = 0.03). Pain scores were low and similar in both groups and the need for additional analgesia was uncommon. Comparison of the efficacy of paracetamol versus paracetamol, codeine and promethazine (Painstop) for premedication and analgesia for myringotomy in children. Ragg P, et al. Royal Children's Hospital, Melbourne, Victoria. Anaesth Intensive Care. 1997 Feb;25(1):29-32.

Newborns on Ventilation: Huge Study Finds Morphine No Benefit: The Neurologic Outcomes and Pre-emptive Analgesia in Neonates (NEOPAIN) study of 898 preterm babies on ventilation received either placebo or morphine for up to 14 days. Additional open-label morphine could be given on clinical judgment (placebo group 242/443 [54.6%], morphine group 202/446 [45.3%]). Both groups had similar outcomes with no impact on neonatal death (11% placebo vs. 13% morphine),  severe intraventricular hemorrhage (11% vs. 13%), or periventricular leucomalacia (9% vs. 7%). Those given extra open-label morphine did much worse, but this may not have been related to the extra morphine. The morphine doses used in this study decrease clinical signs of pain but can cause significant adverse effects in ventilated preterm neonates. Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial. Anand KJ et al. University of Arkansas. . Lancet. 2004 May 22;363(9422):1673-82.

Out-Patient Surgery: Ketamine as Good as Remifentanil Before Anesthetic Induction: In a DB study of 75 children ages 1-7 undergoing out-patient surgery, IV remifentanil 1 mcg/kg was compared to IV ketamine 0.7 mg/kg or placebo before anesthetic induction. Anesthesia was induced with propofol and maintained with O2-N2O-sevoflurane. The required induction dose of propofol was lower for remifentanil and ketamine compared to placebo. After tracheal intubation, heart rate and blood pressure were better attenuated with remifentanil than with ketamine or placebo. In the recovery room, children in the placebo group received more doses of oxycodone than the other two groups but this did not reach statistical significance. There were no differences between the groups in achieving predetermined recovery end-points, attaining full points on the Steward score or in the well being at home. Comparison of remifentanil versus ketamine for paediatric day case adenoidectomy. Tarkkila P, et al. Helsinki University Central Hospital, Finland. Acta Anaesthesiol Belg. 2003;54(3):217-22. Ed: Oxycodone was used as the rescue medication in this study.  However, extensive research suggests that several non-narcotics would have done better.

Out-Patient Surgery: Midazolam Pretreatment Better Separation and Induction than Meperidine Combination: In a DB study of 102 children undergoing out-patient surgery, pretreatment with 0.5 mg/kg midazolam resulted in significantly better improvement in scores at both separation and induction (P < .01) than .2 mL/kg of a combination of meperidine 6.0 mg/mL, atropine 0.08 mg/mL, and diazepam 0.6 mg/mL 15-45 minutes before separation from parents. In the meperidine/atropine/diazepam group, unacceptable scores were strongly associated with younger subjects (P < .01). There were no differences in analgesic requirements, side effects, or time to discharge between groups. Oral midazolam versus meperidine, atropine, and diazepam: a comparison of premedicants in pediatric outpatients. Pywell CA, et al. AANA J 1995 Apr;63(2):124-30. 

Painful Procedures Better than Ketamine than Meperidine: In a DB study of 29 children requiring sedation for suturing, wound or burn debridement, or lumbar puncture, ketamine 4 mg/kg (KET) with combined meperidine 2 mg/kg, promethazine, and chlorpromazine (MPC), patients in the 2 groups had a similar duration of sedation, patients receiving KET had more rapid onset of sedation (3 min vs 18 min, P < .01) a shorter time to discharge (85 min vs 113 min, P 0 .01) and lower Observational Scale of Behavioral Distress scores (9.9 vs 19.2, P = .003). All 15 physicians using KET would request it again vs 5 of 12 (42%) of the physicians using MPC (P < .001). Intramuscular ketamine is superior to meperidine, promethazine, and chlorpromazine for pediatric emergency department sedation. Petrack EM, et al.  Case Western Reserve University. Arch Pediatr Adol Med 1996 Jul;150(7):676-81.

Post-Op Pain Relief was Somewhat Better with Ketorolac than with Morphine: In a DB study of 102 children receiving post-op care, a single dose of did better at pain relief than a single dose of morphine with fewer needing additional although the differences did not reach statistical significance. There was no abnormal postop bleeding or altered renal function from the ketorolac. A randomized comparison of ketorolac tromethamine and morphine for postoperative analgesia in critically ill children. Lieh-Lai MW, et al. Children's Hospital of Michigan, Detroit. Crit Care Med. 1999 Dec;27(12):2786-91.

Tonsillectomy: Ketoprofen Better than Tramadol: In a DB PC study of 45 children (9-15 years) undergoing tonsillectomy, ketoprofen (2 mg/kg) did better than tramadol (1 mg/kg) after induction of anesthesia. Upon completion of surgery, the study treatment was continued as a 6 h intravenous (i.v.) infusion of another dose of saline, ketoprofen (2 mg/kg) or tramadol (1 mg/kg). Postoperatively, each patient received rescue analgesia with patient-controlled analgesia (PCA) device programmed to deliver 0.5 microg/kg) bolus doses of fentanyl. The total number of requests of PCA-fentanyl was significantly less in ketoprofen group compared with tramadol and placebo groups (P = 0.035 and P = 0.049) and the VAS scores for pain were significantly lower in ketoprofen group compared with tramadol (P = 0.044) or placebo groups (P = 0.018) during the first six postoperative hours. Measured intraoperative blood loss was greater in ketoprofen-treated patients than in those receiving placebo (P = 0.029). Ketoprofen and tramadol for analgesia during early recovery after tonsillectomy in children. Antila H, et al. University of Turku, Finland. Pediatr Anethes 2006 May;16(5):548-53.

Tonsillectomy in Children: Tramadol, Ketamine, and Meperidine All Similar in Effectiveness: In a DB study of 45 children undergoing tonsillectomy comparing intramuscular 0.5 mg/kg ketamine, 1 mg/kg tramadol or 1 mg/kg meperidine on post-operative pain, the effects of ketamine, meperidine and tramadol on post-operative pain following adenotonsillectomy in children were similar. Pain relief for children after adenotonsillectomy. Ertugrul F, et al. Akdeniz University , Antalya , Turkey . . J Int Med Res 2006 Nov-Dec;34(6):648-54.  

Tonsillectomy: Ketorolac as Good as Fentanyl for Pain: In a DB study of 57 children, IV ketorolac (1 mg/kg) was as effective at pain control as fentanyl (2 microg/kg) during a standardized general anaesthetic with propofol infusion. The incidence of PONV was low and equal in both groups. Postoperative pain scores were equal at all stages of followup. Intraoperative ketorolac is an effective substitute for fentanyl in children undergoing outpatient adenotonsillectomy. Keidan I, et al. Sackler Faculty of Medicine, Tel Aviv University, Israel. . Pediatr Anesth 2004 Apr;14(4):318-23.

Tonsillectomy: Acetaminophen as Good as Acetaminophen with Codeine; Fewer Side-effects: In a DB study of 51 children ages 3 to 12 with outpatient tonsillectomy, there was no difference in the level of postoperative pain reported by the parents and children between plain acetaminophen and acetaminophen with codeine. The acetaminophen with codeine group tended to have increased problems with nausea, emesis, and constipation. Children in the acetaminophen group consumed a significantly higher percentage of a normal diet on the first 6 postoperative days (P < .05, all time points). Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Moir MS, et al. Stanford University. Laryngoscope. 2000 Nov;110(11):1824-7.

Tonsillectomy: Ketamine Does Just About as Well as Morphine: Ketamine is an NMDA agonist. In a DB study of 80 children ages 6-15 undergoing tonsillectomy, IM morphine 0.1-0.15 mg/kg after induction did slightly better after 30 minutes of extubation than ketamine 0.5-0.6 mg/kg (7 vs. 6 on 10-point CHEOPS scale), but pain relief was similar thereafter. There were no differences in supplemental analgesia requirements (8 vs. 7 patients), or bad dreams (1 vs. 2). Ketamine can be used with NSAIDs, but additive side-effects may occur if combined with morphine. Authors conclude that ketamine is an alternative analgesic for children undergoing tonsillectomy. Comparison of ketamine and morphine for analgesia after tonsillectomy in children. Marcus RJ, et al. Leicester Royal Infirmary, UK. Br J Anaesth. 2000 Jun;84(6):739-42.

Tonsillectomy: Ketorolac Caused Much Less Vomiting but Slightly More Bleeding than Morphine: In a DB study of 96 children after tonsillectomy, received morphine 0.1 mg/kg or ketorolac 1 mg/kg IV, those given ketorolac had many fewer episodes of vomiting than morphine subjects (median 1 vs 3; P = 0.006). While ketorolac patients had a a little more bleeding requiring intervention; 5/49 vs 0/47, P = 0.03) in the first 24 h after surgery, there was no greater overall highly incidence of bleeding than the morphine subjects. Recovery and complications after tonsillectomy in children: a comparison of ketorolac and morphine. Gunter JB, Varughese AM, Harrington JF, Wittkugel EP, Patandar SS, Matar MM, Lowe EE, Myer CM 3rd, Willging JP.  University of Cincinnati. Anesth Analg. 1995 Dec;81(6):1136-41. Ed: This study is strange in that it didn't study pain, which is the primary reason these medicines were given. If Ketorolac was better for pain (very likely), that would be an important benefit to consider, in addition to its lack of priming for future addiction, in making a decision on which to use. According to the above, for every extra bleeding requiring intervention caused by ketorolac, morphine causes 20 episodes of vomiting.  If I had my choice, I would gladly choose to avoid the narcotic and its 20 extra episodes of vomiting by accepting the extra unit of packed cells.  If a doctor asked me if I would rather accept a unit of packed cells or have 20 episodes of vomiting, there is no doubt in my mind which I would choose!

Urologic or Abdominal Surgery: Fentanyl Not Needed for Epidural Anesthesia: In a DB study of perioperative epidural levobupivacaine with and without fentanyl in 120 children ages 6-months to 12 years undergoing urologic or abdominal surgery with epidural solutions as a continuous infusion for 24 h of 0.125% levobupivacaine; 0.0625% levobupivacaine; 1 mug/ml fentanyl; or the combination, 0.0625 levobupivacaine and 1 mug/ml fentanyl, the time to the first dose of rescue analgesia in the first 10 h was less in the plain fentanyl group (P < 0.044). All other effects were similar among the four groups. The plasma concentration of levobupivacaine increased during the infusion period, reaching a maximum of 0.76 mug/ml in the 0.125% group and 0.48 mug/ml in the 0.0625% group by 24 h. The plasma concentration of fentanyl also increased steadily, reaching a maximum concentration of 0.37 ng/ml by 24 h. The authors conclude that 0.0625% levobupivacaine without fentanyl is an effective perioperative epidural solution in children. Efficacy, safety, and pharmacokinetics of levobupivacaine with and without fentanyl after continuous epidural infusion in children: a multicenter trial. Lerman J, et al. Children's Hospital of Buffalo, New York. . Anesthesiology. 2003 Nov;99(5):1166-74. Ed: An opiate was used in this study as the rescue medication, but research suggests that non-narcotics would have done better.

Thomas E. Radecki, M.D., J.D.

modern-psychiatry.com

Email: [email protected]