Extended-release Epidural Morphine Research Articles

Meta-analysis of the effect of extended-release epidural morphine versus intravenous patient-controlled analgesia on respiratory depression

Extended-release epidural morphine (EREM) is a single-dose, extended-release epidural morphine formulation intended to provide postoperative pain relief over a 48-hour period. There have been a few randomized controlled trials investigating the use and safety of EREM versus intravenous patient-controlled analgesia with opioids (IV-PCA); however, the adverse event of respiratory depression of this treatment is unclear. The authors have undertaken a meta-analysis to examine this issue. A systematic literature search of the National Library of Medicine's PubMed database was conducted for terms related to EREM. Only randomized controlled trials, in the English language, assessing the rates of respiratory depression of EREM to IV-PCA were included for analysis. Data on pertinent study characteristics and relevant outcomes were extracted from accepted articles. Meta-analysis was performed using the Review Manager 4.2.7 (The Cochrane Collaboration, 2004). A random effects model was used. The authors' literature search yielded three articles which met all inclusion criteria. All studied doses of EREM were evaluated. Pooled estimates (odds ratio) were made for rates of adverse events of respiratory depression. Use of EREM was associated with significantly higher odds of respiratory depression compared to IV-PCA (odds ratio = 5.74; 95% confidence interval: 1.08, 30.54, p = 0.04). Even when examining only Food and Drug Administration approved dosages for EREM, the use of EREM was associated with significantly higher odds of respiratory depression when compared with IV-PCA (odds ratio = 5.80; 95% confidence interval: 1.05, 31.93, p = 0.04). Although perioperative single-dose epidural EREM (versus IV-PCA) was effective for postoperative pain relief for up to 48 hours, it is associated with significantly higher odds of respiratory depression. Further examination of the issue of respiratory depression of epidural EREM may be warranted.

Evaluation of a Single-Dose, Extended-Release Epidural Morphine Formulation for Pain Control After Lumbar Spine Surgery

DepoDur, an extended-release epidural morphine, has been used effectively for postoperative pain control following many orthopaedic and general surgery procedures and has provided prolonged analgesia when compared with Duramorph. The goal of this article was to compare the safety and analgesic efficacy of DepoDur versus Duramorph after lumbar spine surgery. A prospective, randomized, double-blind clinical study was completed at a single extended-stay ambulatory surgery center. All patients over 18 undergoing posterior lumbar spine fusions were considered for the study. Sixty patients were randomly assigned to a control or treatment group. The control group received DepoDur before surgery, while the treatment group received Duramorph. Although results show no significant differences between the two groups in postoperative visual analog pain scale scores, use of pain medication, and adverse events, subjects receiving DepoDur were less likely to receive Naloxone and oxygen supplementation, experience nausea or fever, and were more likely to experience hypotension. DepoDur proved to be safe and effective, offering similar prolonged analgesic activity when compared with Duramorph.

Epidural injection of extended-release morphine during colorectal surgery.

See Article on Page 186-191 Postoperative pain is one of the most serious symptoms in cancer patients. However, many patients receive inadequate pain management despite the existence of established pain treatment guidelines [1]. Normally, pain is not a surgeon's primary concern [2]. However, with enhanced recovery programs and laparoscopic surgery, optimal pain management is a key factor in postoperative care and leads to an improvement in physical performance and pulmonary functions and to a decrease in the length of the hospital stay [3]. Until recently, the optimal duration or route for pain control was not considered during randomized trials [4] and still remains a controversial issue. Peravali described a case series of 280 patients who had undergone open and laparoscopic colorectal procedures under a single epidural injection of extended-release morphine, DepoDur® [5]. These patients had neither an epidural catheter nor an epidural infusion pump. In addition, approximately 30% of all patients did not require any additional opiate analgesia, and only 12% required patient-controlled analgesia at 48 hours [5]. DepoDur® has been used in various orthopedic, obstetric, and gynecological studies, which have demonstrated effective long-lasting analgesia in the absence of large concentrations of opioids, as well as enhanced patient activity levels and satisfaction [6, 7, 8]. To our knowledge, this is the largest case series reporting the use of DepoDur® in colorectal surgery. Peravali did not make direct comparisons with traditional epidural infusions or postoperative analgesics. However, these case 2014.30.4.159series did highlight the advantages of extended-release epidural morphine with tolerable side effects, such as transient hypotension, respiratory compromise, pruritus, and nausea, in the context of colorectal surgery [9]. This prospective study provides an innovative technique for pain management in order to improve the outcomes of postoperative care in colorectal cancer patients and provides encouraging data that justify randomized controlled trails.

Enhancing the Enhanced Recovery Program in Colorectal Surgery - Use of Extended-Release Epidural Morphine (DepoDur®).

PurposeDepoDur® is a single-dose extended-release morphine injection into the epidural space. It is not commonly used, but has many advantages over traditional analgesic regimens. We analyzed a number of these advantages in our case series in the context of the colorectal enhanced recovery program (ERP) and aimed to show that the ERP could be further enhanced by using DepoDur®.MethodsWe conducted a prospective audit of all patients undergoing open and laparoscopic colorectal procedures where DepoDur® was used between July 2010 and April 2012. Validated pain scores were used, and primary outcome measures were resting and dynamic pain, mobilization, and need for additional analgesia.ResultsTwo hundred eighty patients were included in the case series. Good pain control was seen at 24 and 48 hours. Eighty-one percent of the patients required simple analgesia alone at 24 hours, and 62% required simple analgesia (paracetamol +/- nonsteroidal anti-inflammatory drugs) alone at 48 hours. Only a minority required additional oramorph and patient-controlled analgesia at 24 and 48 hours (19% at 24 hours and 38% at 48 hours). Seventy-nine percent of the patients were mobilized at 24 hours, and 88% of the patients were mobilized at 48 hours.ConclusionDepoDur® is an effective alternative to conventional pain management techniques and may have a role in further enhancing the ERP.

Recent Management Advances in Acute Postoperative Pain

Acute postoperative pain remains a major problem, with both undertreatment and overtreatment leading to serious consequences, including increased risk of persistent postoperative pain, impaired rehabilitation, increased length of stay and/or hospital readmission, and adverse events related to excessive analgesic use, such as oversedation. New analgesic medications and techniques have been introduced that target the preoperative, intraoperative, and postoperative periods to better manage acute postoperative pain, with improvements in analgesic efficacy and safety over more traditional pain management approaches. This review provides an overview of these new analgesic medications and techniques. Specific topics that are discussed include the use of preoperative nonsteroidal anti-inflammatory drugs, anxiolytics, and anticonvulsants; intraoperative approaches such as neuraxial analgesia, continuous local anesthetic wound infusion, transversus abdominis plane block, extended-release epidural morphine, intravenous acetaminophen, and intravenous ketamine; and postoperative use of intravenous ibuprofen, new opioids (eg, tapentadol) or opioid formulations (morphine-oxycodone), and patient-controlled analgesia. New, targeted, analgesic medications and techniques may provide a safer and more effective approach to the management of acute postoperative pain than traditional approaches such as postoperative oral analgesics.

Multimodal pain management for total hip arthroplasty

Multimodal pain management uses a variety of pharmacological agents administered at different perioperative times to target both peripheral and central nerve transduction and the various biochemical pathways, enzymes and receptors that signal painful stimuli and inflammation. This article reviews the role of patient-controlled analgesia, peripheral nerve blocks, local periarticular injections and extended-release epidural morphine injections that can be used in a multidisciplinary approach to analgesia. By decreasing narcotic consumption and improving pain control, multimodal pain management can reduce the numerous adverse effects associated with increased opioid use and improve mobility with physical therapy, both of which can have a direct effect on decreasing length of stay and reducing serious perioperative complications.

Randomized trial demonstrates that extended-release epidural morphine may provide safe pain control for lumbar surgery patients

Background:Safe and effective postoperative pain control remains an issue in complex spine surgery. Spinal narcotics have been used for decades but have not become commonplace because of safety or re-dosing concerns. An extended release epidural morphine (EREM) preparation has been used successfully in obstetric, abdominal, thoracic, and extremity surgery done with epidural anesthesia. This has not been studied in open spinal surgery.Methods:Ninety-eight patients having complex posterior lumbar surgery were enrolled in a partially randomized clinical trial (PRCT) of low to moderate doses of EREM. Surgery included levels from L3 to S1 with procedures involving combinations of decompression, instrumented arthrodesis, and interbody grafting. The patients were randomized to receive either 10 or 15 mg of EREM through an epidural catheter placed under direct vision at the conclusion of surgery. Multiple safety measures were employed to prevent or detect respiratory depression. Postoperative pain scores, narcotic utilization, and adverse events were recorded.Results:There were no significant differences between the two groups as to supplemental narcotic requirements, pain scores, or adverse events. There were no cases of respiratory depression. The epidural narcotic effect persisted from 3 to 36 hours after the injection.Conclusion:By utilizing appropriate safety measures, EREM can be used safely for postoperative pain control in lumbar surgery patients. As there was no apparent advantage to the use of 15 mg, the lower 10 mg dose should be used.

Single dose, extended-release epidural morphine compared to morphine equivalents for post-laparotomy pain in the gynecologic-oncology patient; A pilot study

Objective: To demonstrate improved post operative pain scores in patients receiving extended-release epidural morphine (EREM) compared to traditional PRN opioids in gynecologic oncology patients undergoing laparotomy in a prospective, randomized, case controlled trial. To date there have been no studies to assess the efficacy and long term recovery benefits of pelvic cancer patients undergoing laparotomy receiving EREM versus intravenous analgesics for post operative pain management. EREM is a single epidural injection before or during surgery and provides pain relief for up to 48h following surgery, and no indwelling catheter is required.

Prior Epidural Lidocaine Alters the Pharmacokinetics and Drug Effects of Extended-Release Epidural Morphine (DepoDur®) After Cesarean Delivery

Prior Epidural Lidocaine Alters the Pharmacokinetics and Drug Effects of Extended-Release Epidural Morphine (DepoDur®) After Cesarean Delivery

Prior Epidural Lidocaine Alters the Pharmacokinetics and Drug Effects of Extended-Release Epidural Morphine (DepoDur®) After Cesarean Delivery

A potential physicochemical interaction between epidural local anesthetics and extended-release epidural morphine (EREM) could negate the sustained release. In this study, we sought to determine the pharmacokinetic and drug effects of prior epidural lidocaine administration on EREM. Thirty healthy women undergoing cesarean delivery were enrolled in this randomized study. Patients received 8 mg EREM 1 hour after either a combined spinal-epidural (intrathecal bupivacaine and fentanyl 20 μg with no epidural medication; group SE) or an epidural anesthetic (epidural 2% lidocaine with fentanyl 100 μg; group E). Maximal concentration (Cmax), time to Cmax (Tmax), and AUC(0-last) (area under the concentration-time curve until the last plasma concentration that was below the limit of quantitation) for morphine levels were determined from a plasma sample at 0, 5, 10, 15, and 30 minutes, and 1, 4, 8, 12, 24, 36, 48, and 72 hours. Drug effects including pain, analgesic use, and side effects were measured for 72 hours after cesarean delivery. Epidural lidocaine administration (20-35 mL) 1 hour before epidural EREM administration increased the Cmax in group E (11.1 ± 4.9) compared with group SE (8.3 ± 7.1 ng/mL) (P = 0.038). There were no significant effects on Tmax and AUC(0-last) of venous morphine between the groups (P > 0.05). There was an increased incidence in vomiting, oxygen use, and hypotension in group E (patients who received lidocaine before EREM). A large dose of epidural lidocaine 1 hour before EREM administration alters the pharmacokinetics and drug effects of EREM. Clinicians must apply caution when EREM is administered even 1 hour after an epidural lidocaine "top-up" for cesarean delivery.

Mean analgesic consumption is inappropriate for testing analgesic efficacy in post-operative pain: analysis and alternative suggestion

Post-operative analgesic consumption is often used as a surrogate measure for pain; analyses of mean data assume a Gaussian distribution and use parametric statistics to assess statistical differences, often in small samples. We used a large individual patient dataset to examine the distribution of analgesic consumption, the validity of such analyses and alternative dichotomous outcomes. Analysis of individual patient data from 913 patients over 48 post-operative hours in five randomised trials. Patients had either epidural injection of placebo or morphine (as sulphate and extended release epidural morphine) and use of patient-controlled analgesia. Post-operative fentanyl consumption was calculated over 0-24, 24-48 and 0-48 h. The distribution of analgesic consumption for all patients over the periods 0-24, 24-48 and 0-48 h was exponential. Most patients used less than 750 μg fentanyl over 48 h; 34% used over 1000 μg fentanyl (100 mg morphine), 13% over 2000 μg and 5% over 3000 μg. Mean, median and mode were very different; 20% of patients consumed almost 60% of post-operative analgesic, and standard deviations were generally larger than means. A useful dichotomous outcome was less than 750 μg fentanyl consumed over 48 h, a level associated with very good or excellent patient pain rating. Use of very good or excellent patient pain rating differentiated between different doses of epidural morphine. Because of a highly skewed distribution, post-operative analgesic consumption is an uncertain method of measuring analgesic efficacy of an intervention designed to limit pain during and after surgery.

Multimodal Pain Management After Total Joint Arthroplasty

Adequate postoperative pain control in patients who have undergone total joint arthroplasty allows faster rehabilitation and reduces the rate of postoperative complications. Multimodal pain management involves the introduction of adjunctive pain control methods in an attempt to control pain with less reliance on opioids and fewer side effects. Current research suggests that traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and the associated cyclooxygenase type-2 (COX-2) inhibitors improve pain control in most cases. Nearly all multimodal pain management modalities have a safe side-effect profile when they are added to existing methods. The exception is the administration of DepoDur (extended-release epidural morphine) to elderly or respiratory-compromised patients because of a potential for hypoxia and cardiopulmonary events.

The Use of Continuous Femoral Nerve Blocks Versus Extended Release Epidural Morphine

The purpose of this study was to compare the effectiveness of continuous femoral nerve block (CFNB) protocol, to extended release epidural morphine DepoDur protocol, in patients having a total knee arthroplasty (TKA) enrolled in a structured joint replacement educational program. Overall, the results of this randomized controlled study demonstrate that CFNB and DepoDur protocol pain strategies were well tolerated in TKA patients during this study with expected side effects and appropriate side effect management. Moreover, the DepoDur protocol enhanced pain management experience and satisfaction and provided superior prolonged analgesia compared with CFNB protocol. The occurrence of adverse events, cost, length of stay, and functional outcomes was comparable between groups.

Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis

This study retrospectively compared the continuous epidural infusion of morphine with a single epidural injection of extended-release morphine for postoperative pain control after arthroplasty. Medical records were reviewed for subjects who had total knee or hip arthroplasty (THA) under spinal anesthesia and received either a continuous epidural infusion of morphine (Group EPID; n = 101) or an extended-release epidural morphine (Group EREM; n = 109) for postoperative pain. Data were collected for three postoperative days (POD) on: pain scores; supplemental opioids; medications for respiratory depression, nausea, and pruritus, and distance ambulated during physical therapy. Pain scores were similar until subjects were transitioned to another analgesic approach on POD 2; after that time, pain scores increased in Group EPID, although they decreased in Group EREM. Supplemental opioids were used more on POD1 in Group EREM than in Group EPID, although time to first opioid and total daily morphine equivalents were similar. Naloxone and antiemetics, not antipruritics, were used more in Group EREM. Distance ambulated after THA was greater in Group EREM than in Group EPID. These results suggest that EREM is associated with better postoperative ambulation and analgesia during the transition to oral or intravenous analgesics, although a higher incidence of side-effects was evident.

Aprepitant vs. Multimodal Prophylaxis in the Prevention of Nausea and Vomiting following Extended-Release Epidural Morphine

Extended-release epidural morphine (EREM) is an effective option for postoperative analgesia following major orthopedic surgery; however, postoperative nausea/vomiting (PONV) is a recognized limitation. The incidence of PONV following prophylactic aprepitant, a neurokinin-1 antagonist, was compared with prophylactic multimodal antiemetic therapy in patients receiving EREM for postoperative analgesia following unilateral primary total knee arthroplasty (TKA). Prospectively collected quality assurance data were examined with Institutional Review Board approval. A sequential, open-label, active matched case-control study compared PONV following EREM in patients receiving ondansetron and dexamethasone, and either metoclopramide, diphenhydramine, or prochlorperazine every 6 hours for the 48-hour study period, to patients receiving aprepitant 40 mg given as a single oral dose in the preoperative holding area. Cases were matched for procedure (TKA), age, epidural morphine dose, and known major risk factors for PONV (sex, smoking, previous PONV/motion sickness). Twelve consecutive patients (3 male; 9 female) receiving aprepitant prior to EREM were matched to 12 patients of the same sex of similar age (range 51 to 84 years.) and EREM dose (range 5 to 12.5 mg) receiving the multimodal regime. The incidence of PONV was significantly less for the aprepitant group where 3 of 12 (25%) had PONV compared with 9 of 12 (75%) in the multimodal group (P = 0.039, Fisher's Exact Test; odds ratio = 0.11; 95% CI: 0.018 to 0.706, P = 0.03). While aprepitant significantly reduced the incidence of PONV compared with a multimodal antiemetic regime, used alone it did not eliminate PONV.

Reduction in Pulmonary Embolism after Total Joint Arthroplasty: Three Years of Experience with Extended-Release Epidural Morphine

A retrospective analysis of 659 patients who had undergone a hip or knee arthroplasty was undertaken to determine the incidence of pulmonary embolism (PE) during the 48-hour period following surgery. Data related to pain control, concomitant medications, length of stay, and adverse reactions were also collated. Patients were evenly divided between those receiving extended-release epidural morphine (EREM: n = 327; mean dose 9.7 mg, range 5 mg to 15 mg) or a control group receiving other treatment for postoperative pain (control: n = 332; 44% of controls had an epidural catheter in place). The incidence of PE was significantly higher in the control group than in the EREM group (control: n = 6 or 1.80% vs. EREM: n = 0). Pain control (by a 10-point verbal numerical rating scale) was significantly improved in the EREM group compared with the control group 48 hours after surgery (2.3 +/- 1.8 vs. 4.7 +/- 2.6) and length of stay was significantly reduced (3.9 +/- 1.5 days vs. 4.5 +/- 2.0 days). Adverse event profiles of the EREM and control groups were consistent with prior published studies with EREM. The use of EREM following lower extremity joint arthroplasty may be associated with a significant reduction in the incidence of PE.

Lessons Learned with Extended-release Epidural Morphine after Total Hip Arthroplasty

An extended-release epidural morphine (EREM) has been introduced to improve postoperative pain management. Studies have shown the effectiveness of this agent in providing better pain control and patient satisfaction for patients undergoing total joint arthroplasty. We evaluated postoperative pain relief by comparing average daily pain scores and opioid use with those of the control group. Safety was measured by comparing the occurrence of postoperative complications, nausea and vomiting, pruritus, and respiratory depression between the two groups. Between February 2006 and March 2008, we selected 203 patients to receive EREM for THA. These patients were matched in a 2:1 ratio with patients undergoing THA and receiving spinal anesthesia. We retrospectively reviewed all major and minor postoperative complications from a prospective database. Patients receiving EREM had lower pain scores than patients not receiving EREM on Postoperative Day 1 (POD 1) but not POD 2, or POD 3. Patients receiving EREM experienced a slightly higher incidence of pulmonary embolism and supraventricular tachycardia. Patients receiving EREM also experienced more nausea and vomiting and pruritus. We found EREM provided better pain relief on POD 1 at the expense of a slightly higher incidence of side effects compared with spinal anesthesia alone. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Analysis of individual patient data from clinical trials: epidural morphine for postoperative pain

Individual patient information from clinical trials is infrequently available, but can provide insights for clinical trials and practice. We analysed individual patient information from five randomized trials (913 patients) of i.v. patient-controlled analgesia (IVPCA) plus epidural placebo, morphine sulphate (MS) 5 mg, or extended-release epidural morphine (EREM; DepoDur) at doses of 5-30 mg, to explore effects of a range of epidural morphine doses. Pain and opioid requirement on first and second postoperative days, dose-response, clinically relevant comparisons of IVPCA without epidural morphine, 5 mg MS, and 10 mg EREM, and relationship between patient rating and other measures were described. There were three strong findings. Epidural morphine resulted in greater patient satisfaction, despite higher rates of adverse events. Those describing their analgesic medication as 'very good' or 'excellent' used IVPCA opioid less and had pain scores significantly below the global mean, whereas those describing their medication as 'poor' or 'fair' had pain scores significantly above the mean. Epidural morphine meant less need for postoperative IVPCA opioid than epidural placebo. The therapeutic gain with EREM was lower pain scores with less IVPCA opioid. Moderate or severe pruritus was more common with IVPCA plus epidural morphine, whatever the formulation, compared with IVPCA plus placebo. Analysis of individual patient data from high-quality clinical trials provides important insights into characteristics of new agents not immediately apparent from original trials, and also informing clinical practice. Prophylactic epidural morphine provides a better patient experience than IVPCA alone.

A randomized study of the serum pharmacokinetics of lower thoracic extended-release epidural morphine (DepoDur®) after lidocaine-epinephrine test dose administration in patients undergoing upper abdominal surgery

The primary objective was to evaluate the serum pharmacokinetic profile of a single 15-mg dose of extended-release epidural morphine (EREM) administered at the lower thoracic epidural space alone or following a lidocaine-epinephrine test dose in patients undergoing major upper abdominal surgery. This randomized, open-label study recruited men and women > or = 18 years of age scheduled for major upper abdominal surgery. Patients were randomly assigned to 1 of 5 treatment groups and were administered a single 15-mg dose of EREM or EREM preceded by a 3 ml lidocaine (1.5%)/epinephrine (1 : 200,000) test dose with or without a saline flush: EREM alone; test dose + flush + 3-minute wait + EREM; test dose + flush + 10-minute wait + EREM; test dose + flush + 15-minute wait + EREM; or test dose + 3-minute wait + EREM. EREM was administered at the lower thoracic epidural intervertebral space (T8 - T12) approximately 30 minutes before the surgical incision. Noncompartmental pharmacokinetic parameters were determined based on the serum concentration-time profiles of morphine and morphine metabolites. Effectiveness and safety were also assessed. The intent-to-treat and safety populations included 39 patients; the pharmacokinetic population included 37 patients. Administration of EREM 3 minutes after a lidocaine-epinephrine test dose, with or without a flush, resulted in an increased mean maximum serum concentration of morphine (Cmax; flush, 30.2 +/- 8.5 ng/ml; no flush, 25.6 +/- 10.1 ng/ml; EREM alone, 11.5 +/- 7.3 ng/ml) and a decreased median time to Cmax (tmax; flush, 0.2 h; no flush, 0.2 h; EREM alone, 2.0 h) compared with administration of EREM alone, without affecting relative morphine bioavailability. Flushing the catheter and waiting 15 minutes normalized the Cmax (11.4 +/- 6.4 ng/ml) but not the median tmax (0.5 h). There were no significant group differences in safety, tolerability, or analgesic effectiveness. The interaction between EREM and a lidocaine-epinephrine test dose administered at T8 - T12 can be minimized by waiting 15 minutes after test dose administration. The overall safety and effectiveness of 15 mg EREM administered at the lower thoracic epidural intervertebral space in patients undergoing major upper abdominal surgery appears similar to that observed in previous studies assessing lumbar administration. ClinicalTrials.gov Identifier: NCT00728832.

A Comparison of Patient Pain Responses and Medication Regimens After Hip/Knee Replacement

Increased emphasis on adequate pain control as a patient expectation and a change in professional practice standards has prompted research on new mechanisms of pain medication delivery in an effort to improve outcomes and efficacy. The purpose of this study was to compare pain scores of patients receiving extended release epidural morphine (EREM) with those receiving traditional pain control regimens. Retrospective chart reviews were performed on all patients who had had first-time, elective, nontraumatic, unilateral hip or knee replacement from January to June 2006. All patients received either intraoperative EREM or a traditional pain control regimen. Medication regimens were coded and noted at patients' arrival on the unit (baseline), at 16 hr, and at 48 hr postoperatively. The sample consisted of surgical patients (N = 65) having first-time, nontraumatic hip/knee surgery. Of the sample, 39% (n = 25) were men and 61% (n = 40) were women, with a mean age of 65.25 years (SD = 15.28). Knee replacement surgery was the most frequent surgery at 57% (n = 36), with women representing 75% (n = 28) of the total knee surgical procedures. Hip surgical procedures were equally divided between men (n =11) and women (n = 11). Postoperative pain was assessed within 1 hr of admission to the unit for 98.5% (n = 64) of patients and reassessed at 15-17 hr for 90.8% (n = 59) of the sample, suggesting that the assessment and documentation of patient pain level were a high priority for the nurses. Pain scores were not correlated with age during the 3 time points in the study. Women reported a significantly higher level of pain upon admission to the unit than men, t(62) = 2.697, p <or= .009027. Pain scores for both groups were relatively low with an average score of 3.1 at the time of postoperative admission decreasing to an average of 2.7 at 16 and 24 hours. There were no significant differences in patients reported pain levels between the EREM and traditional control regimens.