Original Contribution Predicting morphine related side effects in the ED: An international cohort study ☆ Vincent Bounes a,b, ⁎, Béatrice Charriton-Dadone c , Jacques Levraut d , Cyril Delangue e , Françoise Carpentier f , Stéphanie Mary-Chalon g , Vanessa Houze-Cerfon h , Agnès Sommet i , Charles-Henri Houze-Cerfon h , Michael Ganetsky j a Pôle Médecine d'Urgence, Hôpital Universitaire de Purpan, Toulouse 31059 Cedex 9, France b INSERM UMR 1027, Université Paul Sabatier, Toulouse 31000, France c Service d'Accueil des Urgences (SAMU 47), Centre Hospitalier d'Agen, Agen 47923, France d Pôle Médecine d'Urgence, Hôpital Universitaire de Nice, Nice 06000, France e Service d'Accueil des Urgences, Centre Hospitalier de Dunkerque, Dunkerque 59385, France f Pôle Urgences Médecine Aigüe, Hôpital Universitaire des Alpes, Grenoble 38043 Cedex 9, France g Pôle Médecine d'Urgence, Centre Hospitalier Comminges Pyrénées, Saint-Gaudens 31806, France h Pôle Médecine d'Urgence, Hôpitaux Universitaires de Toulouse, Toulouse 31059 Cedex 9, France i Service de Pharmacologie Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmaco-épidémiologie et d'Informations sur e médicament, Hôpital Universitaire de Toulouse, Toulouse 31059 Cedex 9, France j Department of Emergency Medicine Administrative Offices, West CC-2, Beth Israel Deaconess Medical Center, 1 Deaconess Place, Boston, MA 02215, USA abstract article info Article history: Received 28 June 2016 Received in revised form 25 November 2016 Accepted 28 November 2016 Study objectives: Morphine is the reference treatment for severe acute pain in an emergency department. The purpose of this study was to describe and analyse opioid-related ADRs (adverse drug reactions) in a large cohort of emergency department patients, and to identify predictive factors for those ADRs. Methods: In this prospective, observational, pharmaco-epidemiological international cohort study, all patients aged 18 years or older who were treated with morphine were enrolled. The study was done in 23 emergency de- partments in the US and France. Baseline numerical rating scale score and initial and total doses of morphine ti- tration were recorded. Logistic regression analysis was used to study the effects of demographic, clinical and medical history covariates on the occurrence of opioid-induced ADRs within 6 h after treatment. Results: A total of 1128 patients were included over 10 months. Median baseline initial pain scores were 8/10 (7– 10) versus 3/10 (1–4) after morphine administration. Median titration duration was 10 min (IQR, 1–30). The oc- currence of opioid-induced ADRs was 25% and 2% were serious. Patients experienced mainly nausea and drows- iness. Medical history of travel sickness (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.01–2.86) and history of nausea or vomiting post morphine (OR, 3.86; 95% CI, 2.29–6.51) were independent predictors of morphine re- lated ADRs. Conclusion: Serious morphine related ADRs are rare and unpredictable. Prophylactic antiemetic therapy could be proposed to patients with history of travel sickness and history of nausea or vomiting in a postoperative setting or after morphine administration. © 2016 Published by Elsevier Inc. Keywords: Analgesia Morphine Side effects Emergency department 1. Introduction Most international guidelines and clinical consensus recommend in- travenous morphine for the management of severe acute pain in the emergency department setting [1-3]. Aggressive titration protocols have been proposed to overcome poor response to morphine for some patients [4]. Studies focus on improving the efficacy of opioid analgesia; however very few studies were exclusively based on improving safety. The incidence of opioid-induced ADRs (adverse drug reactions) in an emergency department setting in the literature varies between 11% and 23% [5-10]. The clinical response to opioids is, however, highly var- iable and occurrence of ADRs could be affected by factors not related to the dose [11]. An appealing strategy should be to find easily identifiable characteristics of patients that predict response to opioids and to use these factors to modify interventions. In 2009, a study of 277 patients failed to detect any associated factors; however it had a small sample size [12]. Our goal was then to find identifiable characteristics that American Journal of Emergency Medicine 35 (2017) 531–535 ☆ Trial registration: NCT01654055. ⁎ Corresponding author at: Pôle Médecine d'Urgence, Hôpital Universitaire de Purpan, Toulouse 31059 Cedex 9, France. E-mail address: bounes.v@chu-toulouse.fr (V. Bounes). http://dx.doi.org/10.1016/j.ajem.2016.11.053 0735-6757/© 2016 Published by Elsevier Inc. Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Downloaded for Anonymous User (n/a) at Maimonides Medical Center - JC from ClinicalKey.com by Elsevier on January 16, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.