Anaesthesia, 1991, Volume 46, pages 538-540

Morphine compared with diamorphine

A comparison of dose requirements and side-effects after hip surgery

S. L. ROBINSON, D. J. ROWBOTHAM AND G. SMITH

Summary
The dose requirements and side effects of morphine were compared with those of diamorphine administered by patient-controlled
analgesia in 40 patients following elective total hip replacement. Patients were allocated randomly to receive in a double-blind
manner either morphine or diamorphine for postoperative pain relief: There were no signijkant differences between the two
groups with regard to postoperative sedation, nausea, well-being, pain relief and requirements for antiemetic drugs. The dose
requirement for diamorphine was approximately 50% of that for morphine.

Keywords
Analgesia; postoperative.
Analgesics; diamorphine, morphine.
Equipment; patient-controlled analgesia.

It is frequently stated that diamorphine causes less nausea,
vomiting and sedation and more euphoria than morphine,’
although it is difficult to find convincing data to support
this contention. It has been reported also that diamorphine
is twice as potent as
Morphine has been accepted as the standard potent
analgesic for many years whereas diamorphine achieved
popularity in medical practice only during the first half of
this century. It was preferred to morphine because of its
greater potency and more rapid onset of action. Increasing
illegal use led to its total ban for medicinal use in the USA
in 1924. Diamorphine is often more popular than morphine
where it is still available, in the UK for example, parti-
cularly in the relief of terminal pain and coronary care.
This study was designed to compare the relative potency
and side effects of morphine and diamorphine administered
for pain relief after total hip replacement via a patient-
controlled analgesia system (PCAS).
Methods
Forty patients, ASA grades 1-2, aged 4-80 years, under-
going total hip replacement were studied. All patients gave
written informed consent to the study which was approved
by the local Ethics Committee. Patients who were receiving
opioid, sedative or antidepressant therapy and patients
undergoing repeat surgery were not studied.
Patients were instructed in the use of a patient-controlled
analgesia machine (Graseby) at an interview before-
hand. The visual linear analogue scoring (VAS) method
for assessment of sedation, nausea and well-being was
also explained. Each linear analogue comprised a 10 cm
unmarked line, the ends of which denoted the extremes
of the variables in question, i.e. wide awake, unable to stay
awake; no nausea, worst possible nausea; very unhappy,
delighted with everything.
All patients were premedicated with temazepam 10-20
mg orally 1 hour before surgery. Anaesthesia was induced
with thiopentone 3-4 mg/kg and tracheal intubation was
facilitated by the use of a nondepolarising muscle relaxant.
The lungs were ventilated with 66% nitrous oxide and a
small concentration of a volatile agent in oxygen for main-
tenance of anaesthesia. Anaesthesia was supplemented with
morphine 0.1-0.2 mg/kg. Morphine was administered
intravenously in 2 mg increments in the recovery room
until pain control was judged to be satisfactory by the
anaesthetist.
Patients were allocated randomly on return to the ward
to receive morphine or diamorphine by PCAS, which was
programmed to deliver morphine 2 mg or diamorphine 1
mg on demand with a lockout interval of 10 minutes for
both groups. Operation of the PCAS was recorded by a
printer (Hewlett Packard) which registered the time and
success of a patient demand. Intramuscular metoclopra-

S.L. Robinson, BA, RGN, RMN, Research Sister, D.J. Rowbotham, MD, MRCP, FFARCSI, FCAnaes, Senior Lecturer,
G . Smith, BSc, MD, FCAnaes, Professor, University Department of Anaesthesia, Leicester Royal Infirmary, Leicester
LEI 5WW.
Accepted 10 December 1990.

0003-2409/91/070538 +03 $03.00/0 @ 1991 The Association of Anaesthetists of Gt Britain and Ireland 538
 Morphine compared with diamorphine 539

mide 10 mg was given for nausea at the discretion of the

nursing staff.
Visual analogue scores for sedation, nausea and well-
being were made at 4, 8, 16, 20 and 24 hours after PCA was
started. Pain, nausea and well-being was assessed by a
verbal three-point scoring system at the end of the 24-hour
study period; severe, moderate and slight or none at all, for
pain and nausea; miserable, average and happy for
well-being.
Data were analysed by unpaired Student’s t-test,
Wilcoxon rank sum test and Chi-squared test with Yates’
correction as appropriate. MANOVA for repeated
measures was used for visual analogue scores.

Results
Four patients in the morphine group were excluded from
analysis because of protocol violations. Patients were well
matched for age, sex and weight (Table 1).
There were no significant differences between the
morphine and diamorphine groups with respect to mean
doses of morphine administered in the operating theatre
and in the recovery room (Table2). Mean (SD) 24-hour
postoperative consumption after return to the ward was 44
(27.1) mg of morphine in the morphine group compared I I I I I I I
with 20.2 (10.5) mg of diamorphine in the diamorphine 0 8 16 24
Time (hours)
group (p = 0.004). No patient self-administered the maxi-
mum dose of opioid available. Fig. 1. Mean (SEM) Visual analogue scores (VAS) for nausea
There were no significant differences between the groups sedation and well-being. There were no significant differences
p = 0.66, 0.78 and 0.51 respectively. Morphine, 0-0;
in the requirements for metoclopramide (p = 0.50; Table 3) Diamorphine, A-A.
or in the VAS for nausea, sedation or well-being (p = 0.66,
0.78 and 0.52 respectively; Fig. 1).
The verbal three-point scores (Table 4) for overall experi-
ence of pain, nausea and well-being are shown in Table 4.
Table 1. Patient data; (mean (SD)). There were no significant There were no significant differences.
differences.

Morphine Diamorphine Discussion

group group
(n=16) (n =20) We found no significant differences between the groups
over a 24-hour period in the degree of euphoria, nausea
Sex; m :f 7:9 7: 13
Age; years 62.3 (8.4) 58.0 (10.2) and vomiting or sedation, as assessed by subjective visual
Weight; kg 68.5 (14.0) 66.4 (16.4) analogue scores, or in pain relief, nausea and euphoria as
Duration of surgery; hours 1.87 (0.5) 1.95 (0.9) assessed by verbal rating. There was, in addition, no signifi-
cant difference in the requirements for antiemetics between
Table 2. Mean (SD) (95% confidence intervals) dose of morphine the two groups. Both groups demonstrated relatively low
(mg) given during surgery and in the recovery room. There were no nausea scores. The mean amount of morphine demanded
significant differences. was approximately twice that of diamorphine.
Morphine Diamorphine
group group P Table 4. Results of the three-point verbal scoring system. There
were no significant differences.
Intra-operative 9.3 (2.2) 10.2 (4.2) 0.43
(8.1-10.5) (8.2-12.2) Morphine Diamorphine
Recovery 2.6 (3.6) 3.5 (3.7) 0.44 group group
(0.6-4.5) (1.8-5.3) (n= 16) (n= 20) P
Pain 0.74
Table 3. Doses of metoclopramide administered intramuscularly. Severe 2
There were no significant differences (p = 0.50). Moderate 13
Slight/none 5
Metoclopramide Morphine Diamorphine Nausea 0.42
doses ( n ) group (4 group (4 Severe 1
Moderate 4
10 10 Slight/none 15
3 5 Well-being 0.07
2 3 Miserable 1 3
0 2 Average 9 4
1 0 Happy 6 13
540 S.L. Robinson, D.J. Rowbotham and G . Smith
The scientific basis for the alleged superiority of diamor-
phine over morphine is dubious and since diamorphine is
metabolised to monacetyl morphine, and morphine itself, it
would be surprising if there were a marked difference. Very
few studies authenticate this claim of superiority and the
present study is no exception.
Smith and Beecher4 reported that impairment of mental
function, described usually as euphoria, following diamor-
phine but not morphine was probably caused by the
increased speed of onset of action of diamorphine when
given in equi-analgesic doses. We found no evidence of
increased rate of onset, or of euphoria, compared with
morphine. One of the reasons for the popularity of diamor-
phine amongst drug abusers is its solubility which may
account for a previous assumed speed of onset of psychic
effects.
Dundee, Loan and Clarke’ in their study of opioids given
as premedication reported no significant difference in the
frequency or intensity of subjective effects of diamorphine,
but they did report that the effects after diamorphine were
of shorter duration (by about 25%) than those of
morphine. They found the toxicity of morphine and
diamorphine was similar but that morphine caused more
emesis than diamorphine and that the latter was more
efficacious. It was stressed that these opioids were given
only in single doses and that repeated doses may lead to
different results. In this study we found no evidence that
morphine was associated with more emesis than
diamorphine.
Foldes, Swerdlow and Siker3estimated that diamorphine
was 2-3.3 times more potent than morphine and Dundee
and colleagues’ observed that diamorphine 5 mg was
approximately equipotent with morphine 10 mg. Our work,
with self-administered intravenous diamorphine and
morphine after hip replacement surgery, confirms these
observations.
We conclude that, with patient-controlled administra-
tion, there is little difference between morphine and
diamorphine and there is no evidence to support the view
held by many clinicians that diamorphine is superior to
morphine in terms of the production of greater euphoria
and less nausea and vomiting.
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