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The addition of intra‐articular sufentanil to a mixture of ropivacaine and clonidine following
anterior cruciate ligament repair provided no additional analgesic benefits (Armellin et al, 2008
Level II). A mixture of intra‐articular bupivacaine and 100 mg tramadol resulted in better pain
relief and lower rescue analgesic requirements than use of either drug alone (Zeidan et al,
2008 Level II).
There is no evidence for analgesic efficacy of peripheral opioids at non‐intra‐articular sites,
including use with perineural blockade (Picard et al, 1997 Level I). While opioid receptors have
been identified in the cornea and skin, topically applied opioids have not consistently
demonstrated efficacy in pain states such as corneal ulceration (fentanyl) (Zollner et al, 2008
Level II), partial thickness burns (morphine) (Welling, 2007 Level II), or chronic skin ulceration
(morphine) (Vernassiere et al, 2005 Level II).
Although commonly used, oral morphine mouthwash in chemotherapy‐induced mucositis pain
has only limited supporting evidence; a dose‐response (beneficial) effect was seen in a small
pilot study using 1 mg/mL and 2 mg/mL morphine mouthwash (Cerchietti et al, 2003 Level II).
Benefit was also evident in a small comparison of morphine mouthwash 30 mg 3‐hourly, with
a local anaesthetic‐based solution, in mucositis associated with chemoradiotherapy in head
and neck cancer patients (Cerchietti et al, 2002 Level II).
Key messages
1. Intrathecal morphine produces better postoperative analgesia than intrathecal fentanyl
after Caesarean section (U) (Level I).
CHAPTER 5 2. Intrathecal morphine doses of 300 mcg or more increase the risk of respiratory depression
(N) (Level I).
3. Morphine injected into the intra‐articular space following knee arthroscopy does not
improve analgesia compared with placebo when administered after surgery (R) (Level I).
4. Evidence for a clinically relevant peripheral opioid effect at non‐articular sites, including
perineural, is inconclusive (U) (Level I).
5. Epidural pethidine produces better pain relief and less sedation than IV pethidine after
Caesarean section (U) (Level II).
6. Extended release epidural morphine provides analgesia for up to 48 hours, however
central depressant effects, including respiratory depression, may also be increased and
prolonged (N) (Level II).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
No neurotoxicity has been shown at normal clinical intrathecal doses of morphine, fentanyl
and sufentanil (U).
Neuraxial administration of bolus doses of hydrophilic opioids carries an increased risk of
delayed sedation and respiratory depression compared with lipophilic opioids (U).
130 Acute Pain Management: Scientific Evidence
