Ketamine may be non-inferior to morphine for out-of-hospital traumatic pain management

1. Ketamine was non-inferior to morphine at analgesic pain reduction for out-of-hospital pain management.

2. There was, however, an increased number of adverse events in the ketamine group, though the majority of these were associated with emergence phenomenon and did not require intervention.

Evidence Rating Level: 1 (Excellent)

Pain is a common symptom experienced outside of the hospital, which is currently being researched to shore up inadequacies, especially for those experiencing traumatic pain. There is much discussion in this research over which analgesic is the best to prescribe for out-of-hospital pain. A large part of this is due to the US facing an opioid crisis. As such, it is important to find strategies to prevent opioid overprescription and overdose. In this randomized control trial, 251 patients were enrolled in a 1:1 ratio to receive ketamine or morphine as an analgesic. Among these participants, 111 (44.9%) were women and 140 (55.1%) were men with a median age of 51 (IQR, 34-69) years. The ketamine group experienced a mean change in pain score of -3.7 (95% CI, -4.2 to -3.2) while the morphine group had a mean change in pain of -3.8 (95% CI, -4.2 to -3.4) (difference, 0.1 [95% CI, -0.7 to 0.9] points). Noninferiority was demonstrated since the upper limit of the CI was lower than the noninferiority threshold. Comparing pain levels, the ketamine group had a faster decline in pain intensity than the morphine group (mean values of pain points per minute: -0.09 [95% CI, -0.10 to -0.08] in the ketamine group and -0.07 [95% CI, -0.08 to -0.05] in the morphine group) and thus experienced a difference of 0.02 [95% CI, 0.01-0.04; P=.14]. When comparing vitals, there was no significant difference between the two groups. Thirty minutes after receiving the assigned drug, the ketamine group had adverse events in 49 out of 120 patients (40.8% [95% CI, 32.0-49.6%]) while the group receiving morphine had them in 19 of 113 (16.8% [95% CI, 10.4%-25%], reporting a risk difference of 24% (95% CI, 12.8%-35.2%). In the ketamine group, the most commonly seen adverse event was the emergence phenomenon (24 of 120 [20%]) whereas in the morphine group, it was nausea (12 of 113 [10.6%]). The use of ketamine intravenously showed noninferiority compared to morphine usage in pain reduction. Although there were more adverse events in the ketamine group, they were found to be minor thus not requiring intervention. Ketamine was shown to have similar pain relief to morphine as an out-of-hospital pain management option while minimizing further opioid proliferation.

Click to read the study in JAMA Network Open

Image: PD

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