In knee surgery, the track record for narcotics is 0 wins, 2 ties, and 8 losses.  Narcotics are losers.  There are five more studies below where narcotics did no better than placebos for intre-articular injection.

Knee Arthroscopy: Morphine No Value: In a DB study of 50 patients undergoing knee arthroscopy under general anesthesia, morphine, bupivacaine, and epinephrine did no better than bupivacaine and epinephrine. Bupivacaine and epinephrine yielded lower pain scores and rescue medication consumption than patients receiving epinephrine alone, which was statistically significant irrespective of the timing of injection (P < .0001). Patients receiving the study medication preoperatively had significantly lower pain scores at the first measurement (t = 0) than those receiving the study medication postoperatively (P = .0343). Short-term analgesic effects of intra-articular injections after knee arthroscopy. Goodwin RC, et al. The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. Arthroscop 2005 Mar;21(3):307-12.

Arthroscopic Surgery: Ketorolac Slightly Better than Hydrocodone/Acetaminophen (Vicodin) for Arthroscopy and Laparoscopy: In an industry-financed DB PC study of 252 patients with moderate to severe post-op pain from arthroscopic or laparoscopic tubal ligation, patients received oral ketorolac 10 mg every 6 h for up to 3 days, or hydrocodone 7.5 mg plus acetaminophen 750 mg every 6 h for up to 3 days, or placebo capsules followed by ketorolac 10 mg every 6 h for up to 3 days. In the patients undergoing arthroscopic surgery, both ketorolac and hydromorphone-acetaminophen provided superior pain relief compared with the placebo. The summed pain intensity difference (SPID), visual analogue scale ( VAS) SPID, and total pain relief scores were higher in the ketorolac group compared with the hydrocodone-acetaminophen group, but the differences were not statistically significant. In tubal ligation surgery, the three treatment groups displayed similar responses to the study medications. However, the ketorolac group scored higher in terms of overall tolerability than the hydrocodone-acetaminophen group. Neither oral analgesic proved to be very effective after laparoscopic tubal ligation. A comparison of oral ketorolac and hydrocodone-acetaminophen for analgesia after ambulatory surgery: arthroscopy versus laparoscopic tubal ligation. White PR, Joshi GP, Carpenter RL, Fragen RJ. University of Texas Southwestern Medical Center at Dallas. Anesth Analg. 1997 Jul;85(1):37-43.

Arthroscopy: Naproxen Relieved Pain Better than Propoxyphene with Acetaminophen: In a 6-hour DB study of 52 patients undergoing arthroscopy, initially moderate (55/100 on VAS scale) post-op pain was less at each hourly interval with naproxen, especially at the 1 hour mark (p=.008). Seven of the propoxyphene patients requested additional pain medication vs. one of the naproxen. Drez D Jr., et al. South Med J 1987 Apr;80(4):440-3.

Arthroscopic Knee Surgery: Ketorolac Superior to Hydrocodone/Acetaminophen: In a DB study of 125 out-patients with an arthroscopically assisted patellar-tendon autograft anterior cruciate ligament reconstruction, a loading dose of parental ketorolac tromethamine was administered and subjects were later given two staged doses of the same "unknown" drug with pain evaluations conducted after each dose. For group 1, dose 1 consisted of ketorolac tromethamine 20 mg orally and dose 2 was ketorolac tromethamine 10 mg. For group 2, both dose 1 and dose 2 consisted of hydrocodone 10 mg plus acetaminophen 1,000 mg orally. Efficacy was evaluated by standard analgesic measures. Outpatients showed lower categorical pain intensity for ketorolac than hydrocodone/acetaminophen at 1 hour (P=.03), 2 hours (P=.006), and 3 hours (P=.02); and lower summed intensity differences for ketorolac at 3 hours (P=.014) and 4 hours (P=.019); and better total pain relief for ketorolac at 3 hours (P=.014) and 4 hours (P=.013). Moreover, ketorolac tromethamine was no more likely to cause digestive complaints than hydrocodone and acetaminophen. No bleeding problems were observed in either group. Comparison of oral ketorolac and hydrocodone for pain relief after anterior cruciate ligament reconstruction. Barber FA, Gladu DE. Plano Orthopedic and Sports Medicine Center, Texas. Arthroscopy. 1998 Sep;14(6):605-12.

Knee Arthroscopy: Intra-Articular Ketorolac 60 mg Reduced Pain Better than Morphine and Add-On Morphine No Significant Increased Benefit: In a DB study of 100 patients ages 15-60 undergoing knee arthroscopy, intra-articular ketorolac 60 mg did better than placebo and better than morphine 3 mg.  Morphine 3 mg combined to ketorolac did not add a significant advantage compared to ketorolac alone for pain relief over the first 48 hours. Postoperative pain following knee arthroscopy: the effects of intra-articular ketorolac and/or morphine. Gupta A, et al. Orebro Hospital Medical Center, Sweden. Reg Anesth Pain Med. 1999 May-Jun;24(3):225-30.

Knee Arthroscopic Surgery: Intra-Articular Morphine of No Value: In a DB study of 320 patients undergoing arthroscopic knee surgery, 15 ml of bupivacaine 0.5%, 5 mg of morphine in 15 ml of isotonic saline solution, 15 ml of bupivacaine 0.5% with epinephrine 0.0005%, or 15 ml of isotonic saline solution were compared. In terms of reducing postoperative pain and decreasing the consumption of analgesics after arthroscopic knee surgery, bupivacaine 0.5% with epinephrine 0.0005% was found to be the most effective. Postoperative analgesic value of the intra-articular instillation of bupivacaine and morphine after arthroscopic knee surgery. Follak N, et al. Ernst Moritz Arndt University, Greifswald, Germany. Arch Orthop Trauma Surg. 2001 May;121(5):278-81.

Knee Arthroscopic Surgery: Anterior Cruciate: Intraarticular Morphine No Value: In a DB study of 62 patients undergoing anterior cruciate reconstruction, postoperative femoral nerve block was effective, and intraarticular morphine provided no additional benefit. Does intraarticular morphine improve pain control with femoral nerve block after anterior cruciate ligament reconstruction? McCarty EC, et al. Vanderbilt Sports Medicine Center, Nashville. Am J Sports Med. 2001 May-Jun;29(3):327-32.

Knee Replacement: Clonidine Much Better than Morphine at Prolonging Surgical Analgesia: In a DB study of 36 elderly patients undergoing knee replacement, 0.15 mg clonidine but not 0.15 mg morphine prolonged surgical analgesia when added to 10 mg plain bupivacaine. 1/9 in the clonidine group, 8/10 in placebo and 8/11 in morphine (P < 0.05) received reinjection of bupivacaine for surgical pain. These injections were given about 2 1/2 hr after the initial intrathecal injection, the duration of anaesthesia being about four hours. Comparison of clonidine, morphine or placebo mixed with bupivacaine during continuous spinal anaesthesia. Brunschwiler M, et al. University Hospital of Geneva, Switzerland. Can J Anaesth. 1998 Aug;45(8):735-40.

Knee Replacement: Morphine Inferior to Both IV Parecoxib and Ketorolac: In a DB study of 208 adults after unilateral total knee replacement of IV parecoxib sodium 20 and 40 mg, morphine 4 mg, and ketorolac 30 mg or placebo within 6 hours of discontinuation of patient-controlled analgesia on postoperative day 1. Onset of analgesia was similarly rapid with IV parecoxib sodium 40 mg, morphine, and ketorolac. Level and duration of analgesia were significantly superior for both ketorolac and parecoxib compared to morphine. Intravenous parecoxib sodium foracute pain after orthopedic knee surgery. Rasmussen GL, et al. Orthopedic Specialty Hospital, Murray, Utah. Am J Orthop. 2002 Jun;31(6):336-43.

Knee Replacement: Intrathecal Neostigmine Preferred to Morphine: In a DB PC study of 60 patients undergoing Knee joint replacement, intrathecal (IT) 0.5% hyperbaric bupivacaine 15 mg with either normal saline 0.5 mL, neostigmine 50 µg, or morphine 300 µg were compared. There was no significant difference in maximal level of sensory block among the three. The morphine had a later onset of postsurgical pain and longer time to first rescue analgesics than neostigmine (P <0.05). Overall 24-hr VAS pain scores were higher with saline vs morphine and neostigmine (P <0.05). Motor block lasted longer with neostigmine than with morphine and saline (P <0.05). Side-effects were similar with neostigmine and morphine except pruritus (70%) occurred much more frequently with morphine (0%; P <0.05). Overall satisfaction was better with neostigmine than morphine or saline (P <0.05). Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesia after total knee replacement surgery. Tan PH, et al. Chang-Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China. . Can J Anaesth. 2001 Jun;48(6):551-6.

Knee Surgery Arthroscopic: Clonidine Gave Longer Pain Relief than Morphine: In a DB study of 30 patients having arthroscopic knee surgery under epidural anesthesia, 150 mcg of clonidine gave longer lasting pain relief post-operatively for 12 hours than did morphine 5 mg, although both did better than placebo. Intra-articular clonidine vs. morphine for post-operative analgesia following arthroscopic knee surgery (a comparative evaluation). Iqbal J, et al. Chandigarh, India. Knee. 2000 Apr 1;7(2):109-113.

Knee Arthroplasty: Intra-Articular Morphine No Better than Bupivacaine and Neither Much Good: In a DB PC study of 105 patients undergoing total knee arthroplasty, intra-articular injections of morphine or bupivacaine were only of minor benefit over placebo with no significant difference between the two. The authors state that the results put into question the benefit of postoperative intra-articular administration of morphine or bupivacaine in patients undergoing TKA. Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty. Mauerhan DR, et al. Miller Orthopaedic Clinic, Charlotte, NC. J Arthroplasty. 1997 Aug;12(5):546-52.

Knee Surgery: Intra-Articular Morphine No Better than Clonidine and Also of no Add-On Benefit: In a DB study of 90 patients undergoing arthroscopy of the knee under general anaesthesia, intra-articular morphine was no better than clonidine and adding the morphine to the clonidine did not increase the benefit.  Intra-articular morphine and clonidine produce comparable analgesia but the combination is not more effective. Gentili M, et al. Rennes, France. Br J Anaesth. 1997 Nov;79(5):660-1

Knee Arthroscopic Surgery: No Benefit IA Morphine, Even in Those with Moderate-Severe Pain: 30-40% of all knee arthroscopic patients have mild or no pain after surgery. Yet, many surgeons inject all patients with intra-articular morphine for pain relief, even these patients with no need for any treatment.  In a DB study of only the 40 out of 57 patients who developed moderate-to-severe pain within 1 h after an arthroscopic procedure under general anesthesia, researchers found no difference in pain relief between an IA injection of saline 10 ml and saline 10 ml with morphine 2 mg. Effective pain relief from intra-articular saline with or without morphine 2 mg in patients with moderate-to-severe pain after knee arthroscopy: a randomized, double-blind controlled clinical study. Rosseland A, et al. Rikshospitalet University Hospital, Oslo, Norway. . Acta Anaesthesiol Scand. 2003 Jul;47(6):732-8.

Joints: Ketoprofen as Effective as Meperidine with Fewer Side-Effects and Longer Action: In a DB study of 59 patients undergoing painful knee arthrolysis and ligamentoplasty, carpal or foot surgery, ketoprofen was as affective as meperidine with pain relief 67% with ketoprofen vs. 63% with meperidine). Pain relief lasted 9.2 h with ketoprofen and 8 h with pethidine. Ketoprofen probably acts more through its central analgesic effect than its antiinflammatory effect. It had fewer side-effects. It does not have the risks of respiratory depression or tolerance unlike the opiate drugs. Comparative study of ketoprofen and pethidine in severe postoperative pain. Langlais F, et al. Hopital-Sud, Rennes. Ann Fr Anesth Reanim 1987;6(5):408-12.

Knee Arthroscopic Meniscectomy: Bupivacaine as Good as Morphine for Intra-Articular Injection: In a DB study of 103 patients ages 16-80 having arthroscopic meniscectomy, 0.25% bupivacaine (50 mg) intra-articular, was just as good at pain relief as 1 mg of 0.1% morphine, or both combines and better than normal saline. Ketorolac [ 30 mg IM] was used as rescue medication. Intra-articular analgesia after arthroscopic knee surgery: comparison of three different regimens. De Andres J, et al. Valencia General University Hospital, Spain. Eur J Anaesthesiol. 1998 Jan;15(1):10-5.

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

modern-psychiatry.com

Email: [email protected]