SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
The Activities on these Portfolio Pages correspond with the learning objectives
of the Guided Learning unit published in Nursing Times 104: 30 (29 July 2008)
and 104; 31 (5 August 2008). The full reference list for this unit follows Activity 4.
Before starting to work through these Activities, save this document onto your
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Date:
ACTIVITY 1
Learning objective: Understand the role
of spinal opioids in postoperative pain
management.
Activity: Consider which patients are
suitable for spinal anaesthesia and
analgesia and examine the advantages
and disadvantages of these methods.
RESPONSE
Begin your response here.
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
ACTIVITY 2
Learning objective: Understand the
importance of postoperative monitoring.
Activity: Explain what observations are
required postoperatively and why. In
addition, evaluate the impact unrelieved
postoperative pain may have on a
patient, both in physiological and
psychological terms.
RESPONSE
Begin your response here.
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
ACTIVITY 3
analgesia and examine the advantages
and disadvantages of these methods.
Learning objective: Understand the role
of spinal opioids in postoperative pain
management.
RESPONSE
Begin your response here.
Activity: Consider which patients are
suitable for spinal anaesthesia and
Nursing Times Portfolio Pages: Spinal opioids in postoperative pain relief
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
ACTIVITY 4
Learning objective: Be aware of the
incidence and treatment of adverse
effects of spinal opioids.
Activity: Postoperative patients should
not experience moderate or severe pain
on movement after surgery. In your
experience is this always the case? If
not, why?
RESPONSE
Begin your response here.
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
FULL REFERENCE LIST
following knee arthroplasty. British Journal
of Anaesthesia; 85: 2, 233-7.
Australian and New Zealand College of
Anaesthetists and Faculty of Pain
Medicine (ANZCA) (2005) Acute Pain
Management: Scientific Evidence (2nd ed).
www.anzca.edu.au/resources/books-andpublications/acutepain.pdf
Coventry, D.M. (2007) Local Anaesthetic
Techniques. In Aitkenhead, A.R. et al
Textbook of Anaesthesia (5th ed).
Edinburgh: Churchill Livingstone.
Baxendale, B.R. (2007) Preoperative
Assessment and Premedication. In
Aitkenhead, A.R. et al Textbook of
Anaesthesia (5th ed). Edinburgh: Churchill
Livingstone.
Beaussier, M. et al (2006) Postoperative
analgesia and recovery course after major
colorectal surgery in elderly patients: A
randomised comparison between
intrathecal morphine and intravenous PCA
morphine. Regional Anaesthesia and Pain
Medicine; 31: 6, 531-538.
Drakeford, M.K. et al (1991) Spinal
narcotics for postoperative analgesia in
total joint arthroplasty. The Journal of Bone
and Joint Surgery; 73: 3, 424-428.
Ene, K.W. et al (2007) Intrathecal
analgesia for postoperative pain relief after
radical prostatectomy. Acute Pain; 9: 6570.
Fogarty, D.J., Milligan, K.R. (1995)
Postoperative analgesia following total hip
replacement: A comparison of intrathecal
morphine and diamorphine. Journal of the
Royal Society of Medicine; 88: 70-72.
Blay, M. et al (2006) Efficacy of low-dose
intrathecal morphine for postoperative
analgesia after abdominal aortic surgery: A
double-blind randomised study. Regional
Anaesthesia and Pain Medicine; 31: 2, 127133.
Gwirtz, K.H. et al (1999) The safety and
efficacy of intrathecal opioid analgesia for
acute postoperative pain: Seven years’
experience with 5969 surgical patients in
an Indiana University Hospital. Anaesthesia
and Analgesia; 88: 599-604.
Bowrey, S. et al (2005) A comparison of
0.2mg and 0.5mg intrathecal morphine for
postoperative analgesia after total knee
replacement. Anaesthesia; 60: 449-452.
Hindle, A. (2008) Intrathecal opioids in the
management of acute postoperative pain.
Continuing Education in Anaesthesia,
Critical Care and Pain; 8: 3, 81-85.
Brennan, F.B. et al (2007) Pain
management: A fundamental human right.
Pain Medicine; 105: 1, 205-221.
Horlocker, T.T. (2003) Regional
anesthesia and anticoagulation in patients
undergoing cardiothoracic and vascular
surgery. Seminars in Cardiothoracic and
Vascular Anesthesia; 7: 4, 417-426.
Candido K.D., Stevens, R.A. (2003) Postdural puncture headache: Pathophysiology,
prevention and treatment. Best Practice &
Research Clinical Anaesthesiology; 17: 3,
451-469.
Cole, P.J. et al (2000) Efficacy and
respiratory effects of low-dose spinal
morphine for postoperative analgesia
Jacobson, L. et al (1989) Intrathecal
methadone and morphine for postoperative
analgesia: A comparison of the efficacy,
duration and side effects. Anaesthesiology;
70: 742-746.
Jacobson, L. et al (1988) A dose-
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
response study of intrathecal morphine:
Efficacy, duration, optimal dose and side
effects. Anaesthesia & Analgesia; 67:
1082-1088.
Janowski, C.J. (2002) Neuraxial
Anesthetic Techniques. In Raj, P.P.
Textbook of Regional Anaesthesia.
Philadelphia: Churchill Livingstone.
Kanner, R.M. (2003) Pain Management
Secrets (2nd ed). Philadelphia: Hanley and
Belfus.
Kehlet, H., Holte, K. (2001) Effect of
postoperative analgesia on surgical
outcome. British Journal of Anaesthesia;
87: 1 62-72.
Koivuranta, M. et al (1997) A survey of
postoperative nausea and vomiting.
Anaesthesia; 52: 5, 443-449.
Kong, S.K. et al (2002) Use of intrathecal
morphine for postoperative pain relief after
elective laparoscopic colorectal surgery.
Anaesthesia; 57: 1168-1173.
Lena, P. et al (2003) Intrathecal morphine
and clonidine for coronary artery bypass
grafting. British Journal of Anaesthesia; 90:
3, 300-3.
Macintyre, P.E., Ready, B.L. (2001) Acute
Pain Management, A Practical Guide (2nd
ed).
London: WB Saunders.
McQuay, H.J., Moore, A. (1998) An
Evidence-Based Resource For Pain Relief.
Oxford: Oxford University Press.
patients undergoing hip arthroplasty.
Anaesthesia & Analgesia; 97: 1709-15.
Naumann, C. et al (1999) Drug adverse
events and system complications of
intrathecal opioid delivery for pain: Origins,
detection, manifestations and
management. Neuromodulation; 2: 2, 92107.
Neal, J.M. (1998) Update on postdural
puncture headache. Techniques in
Regional Anaesthesia and Pain
Management; 2: 202-210
Pickering, S.A.W. et al (2003)
Electromagnetic augmentation of antibiotic
efficacy in infection of orthopaedic implants.
The Journal of Bone & Joint Surgery; 85-B:
4, 588-593.
Power, I., Atcheson, R. (2007)
Postoperative pain. In Aitkenhead, A.R. et
al (2007) Textbook of Anaesthesia (5th ed).
Edinburgh: Churchill Livingstone.
Rathmell, J.P. et al (2005) The role of
intrathecal drugs in the treatment of acute
pain. Anaesthesia & Analgesia; 101: S3043.
Rathmell, J.P. et al (2003) Intrathecal
morphine for postoperative analgesia: A
randomised, controlled, dose-ranging study
after hip and knee arthroplasty.
Anaesthesia & Analgesia; 97: 1452-7.
Rawal, N. (2007) Regional anesthesia
complications related to acute pain
management. In Finucane, B.T. (ed) (2007)
Complications of Regional Anesthesia (2nd
edition) New York: Springer.
Motamed, C. et al (2000) Analgesic effects
of low dose intrathecal morphine and
bupivacaine in laparoscopic
cholecystectomy. Anaesthesia; 55: 118124.
Rawal, N. (2003) Intraspinal Opioids. In
Rowbotham, D.J., Macintyre, P.E. (2003)
Clinical Pain Management: Acute Pain.
London: Arnold.
Murphy, P.M. et al (2003) Optimizing the
dose of intrathecal morphine in older
Rawal, N. (1999) Epidural and spinal
agents for postoperative analgesia.
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
Surgical Clinics of North America; 79: 2,
313-344.
Rawal, N., Allvin, R. (1996) Epidural and
intrathecal opioids for postoperative pain
management in Europe – A 17 nation
questionnaire study of selected hospitals.
Acta Anaesthesiologica Scandinavica; 40:
1119-1126.
Riad, T. et al (2002) Intrathecal morphine
compared with diamorphine for
postoperative analgesia following unilateral
knee arthroplasty. Acute Pain; 4: 5-8.
Safa-Tisseront, V. et al (2001)
Effectiveness of epidural blood patch in the
management of post dural puncture
headache. Anesthesiology; 95: 2, 334-339.
Sakai, T. et al (2003) Mini-dose (0.05mg)
intrathecal morphine provides effective
analgesia after transurethral resection of
the prostate. Regional Anaesthesia and
Pain; 50: 10, 1027-1030.
Slappendel, R. et al (1999) Optimization of
the dose of intrathecal morphine in total hip
surgery: A dose finding study. Anaesthesia
& Analgesia; 88: 822-6.
Stoelting, R.K., Hillier, S.C. (2006)
Pharmacology & Physiology in Anesthetic
Practice (4th ed), Philadelphia: Lippincott,
Williams and Wilkins.
Tan, P.H. et al (2001) Intrathecal
bupivacaine with morphine or neostigmine
for postoperative analgesia after total knee
replacement surgery. Canadian Journal of
Anaesthesia; 48: 6, 551-6.
Togal, T. et al (2004) Combination of lowdose (0.1mg) intrathecal morphine and
patient-controlled intravenous morphine in
the manangement of postoperative pain
following abdominal hysterectomy. Pain
Clinic; 16: 3, 335-341.
Urban, M.K. et al (2002) Reduction in
postoperative pain after spinal fusion with
instrumentation using intrathecal morphine.
Spine; 27: 5, 535-37.
Viscomi, C.M. (2004) Spinal Anesthesia. In
Rathmell, J.P. et al (eds) The Requisites in
Anesthesiology. Philadelphia: Elsevier.
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
ADDITIONAL MATERIAL AND TABLES
Table 1. Definition of terms
Term
Spinal
anaesthesia
Spinal analgesia
Epidural analgesia
Definition
Sensory and motor blockade induced
by the injection of local anaesthetic
into the cerebrospinal fluid (CSF)
The administration of opioid analgesia
into the CSF often given in
combination with spinal anaesthesia
The administration of local anaesthetic
with or without opioid analgesia into
the epidural space to induce sensory
and preferably not motor blockade.
Usually used in the postoperative
period
Anatomy
Spinal cord/CSF
The brain and spinal cord are covered by
the three layered meninges - the dura,
arachnoid and pia mater. The pia mater
is the innermost layer which adheres to
the surface of the brain and spinal cord.
The dura mater forms the outermost
meninges and the arachnoid mater lies
just below the dura - both form the dural
sac. The intrathecal or subarachnoid
space is beyond the dura and contains
cerebrospinal fluid (Viscomi, 2004). The
epidural space contains fat, nerve roots
and blood vessels lying outside the
meninges between the dura mater and
the bones and ligaments of the spinal
canal. Local anaesthetic or analgesic
drugs may be administered via a needle
into the CSF (to produce spinal
anaesthesia or analgesia) or into the
epidural space (to provide epidural
anaesthesia or analgesia).
Mode of delivery
One-off injection
One-off injection
Continuous infusion
via indwelling
epidural catheter
Pain pathways
Nociceptor (pain) input is conducted from
peripheral sites to the spinal cord via
primary afferent A delta and C nerve
fibres. These synapse in the dorsal horn
of the spinal cord and pain impulses are
then transmitted upwards in groups of
neurones (anterior and lateral
spinothalamic tracts) to the brain via the
ascending pathway (Power and
Atcheson, 2007). The dorsal horns
contain a high concentration of opioid
receptors. These are present pre- and
post-synaptically and have an inhibitory
effect on pain transmission. Pain
impulses may be blocked by local
anaesthetics, opioids and other drugs
acting at other receptors, for example,
clonidine or ketamine (Rawal, 1999).
Analgesia is derived by specific opioid
receptor binding in the dorsal horn of the
spinal cord and by non-specific sites in
the white matter.
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Table 2. Spinal opioid dose ranges
Opioid
Morphine
Fentanyl
Diamorphine
Dose range
50–500 mcg
5-25 mcg
500-1000 mcg
Duration of action
Up to 24 hours
1-4 hours
12-18 hours
Table 3. Suggested optimal dose of spinal morphine
Procedure
Total knee arthroplasty
Hip arthroplasty
Hip and knee surgery
(studies combined
patients in sample
group)
Colorectal surgery
Abdominal
hysterectomy
Laparoscopic colorectal
surgery
Laparoscopic
cholecystectomy
Spinal fusion
Transurethral resection
of prostate
Radical prostatectomy
Coronary artery bypass
surgery
Nephrectomy
Abdominal aortic
surgery
Dose
M 300mcg (Riad et al, 2002)
M 300mcg (Tan et al, 2001)
M 300mcg (Cole et al, 2000)
M 500mcg (Bowrey et al, 2005)
M 100mcg (Murphy et al, 2003)
M 100mcg (Slappendel et al, 1999)
M 200mcg (Niemi et al, 1993)
M 1.0mg (Fogarty and Milligan, 1995)
M 200mcg plus morphine PCA (Rathmell et al,
2003)
M 300mcg or 1mg (Jacobson et al, 1988)
M 400–500mcg (Gwirtz et al, 1999)
M 500mcg (Drakeford et al, 1991)
M 500mcg or 1mg (Jacobson et al, 1989)
M 300mcg plus morphine PCA (Beaussier et al,
2006)
M 100mcg plus morphine PCA (Togal et al, 2004)
M 400-500mcg (Gwirtz et al, 1999)
M 200mcgmorphine (Kong et al, 2002)
M 75 or 100mcg (Motamed et al, 2000)
M 20mcg/kg (Urban et al, 2001)
M 50mcg (Sakai et al, 2003)
M 200-300mcg (Gwirtz et al, 1999)
M 100-200mcg (Ene et al, 2007)
M 4mcg/kg morphine + clonidine 1mcg/kg (Lena et
al 2003)
M 600–650mcg (Gwirtz et al, 1999)
M 200mcgplus IV nefopam and morphine (Blay et
al, 2006)
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
Interpreting the studies
There are a number of problems in
the interpretation of these findings,
principally because study
methodology was inconsistent.
Specifically, pain assessment
measurement tools were not
standardised and included
assessment at rest and on
movement (Tan et al, 2001;
Fogarty and Milligan, 1995; Niemi
et al, 1993). In addition, rescue
analgesia was given on patient
request in some studies and
according to pre-assigned pain
scores in others. The
administration of supplementary
analgesia at a pre-determined
pain score (such as VAS >40) is a
more valid and reliable
measurement of additional
analgesic need (Bowrey et al,
2005; Tan et al, 2001).
to procedure. Typically, patients
undergoing total knee replacement
surgery required a greater dose of
morphine to achieve effective
analgesia than those having total
hip replacement (Rathmell et al,
2003). This is likely related to the
greater degree of mobility required
in the prosthetic knee joint than is
needed in a prosthetic hip joint.
Scrutiny of the type of surgeries in
Table 3 reveals that it has not
been widely used for patients
undergoing major abdominal
surgery that involves a midline
laparotomy. The few studies in this
area have concluded that it has a
limited role because analgesia will
be typically required via the
parenteral route for 4-5 days.
These studies failed to show any
beneficial effect of spinal
analgesia on the postoperative
recovery course (Beaussier et al,
2006).
It is also apparent that the dose
requirement varies from procedure
Box 1. Contraindications for spinal anaesthetic and a spinal opioid
(Coventry, 2007)






Untrained medical or nursing staff
Patient unwilling to consent
Generalised or local sepsis
Anticoagulant therapy
Thrombocytopenia or clotting disorder
Central or spinal neurological disease/raised intracranial pressure
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SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF
Box 2. Clinical requirements for the use of spinal opioids (based on
guidance developed at Cardiff and Vale NHS Trust, 2006)








Appropriate protocols for the administration and postoperative patient
monitoring
Regular review (at least daily) by member of the acute pain service or
anaesthetist
24-hour access to on-call anaesthetist should the need arise for advice on
treatment of side- effects or inadequate analgesia
Provision of rescue analgesia and treatment for side-effects
Standardised prescriptions
Education for nursing and medical staff
Provision for suitable titration onto alternative analgesic once the effect of spinal
opioid has diminished
Patients able to tolerate oral analgesia within 18-24 hours after surgery.
Box 3. Nursing care (based on adult guidance developed by the acute
pain service at Cardiff and Vale NHS Trust, 2006)





Patent IV cannula
Observations of blood pressure, pulse, pain, sedation, nausea, respiratory rate
and oxygen saturation level should be initiated half-hourly for two hours, then
two-hourly thereafter up to 24 hours
Regular paracetamol, IV/PR or PO should be prescribed 1g qds
If indicated, regular NSAID for example, diclofenac 50mg tds can be
administered
If rescue analgesia is needed within the first 24 hours then consider giving
tramadol 50-100mg qds or codeine phosphate 30-60mg qds.
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