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Less IS less: a randomised controlled trial comparing cautious and rapid nalbuphine dosing regimens
  1. M Woollard1,
  2. R Whitfield1,
  3. K Smith2,
  4. T Jones2,
  5. G Thomas2,
  6. G Thomas2,
  7. C Hinton2
  1. 1Pre-hospital Emergency Research Unit, Welsh Ambulance Services NHS Trust/University of Wales College of Medicine, Cardiff, UK
  2. 2Welsh Ambulance Services NHS Trust
  1. Correspondence to:
 Malcolm Woollard
 The Old Plough, Llangattock, Powys NP8 1HU, UK;


Objective: This study aimed to determine which of two paramedic administered nalbuphine dosing regimens combined the greater analgesic effect with the minimum of adverse events.

Methods: Patients suffering from chest pain or trauma were randomised to receive either a rapid dosing regimen (10 mg over 30 seconds, repeated once after three minutes if pain score remained above three) or a cautious regimen (5 mg over two minutes, repeated at three minute intervals if pain score remained above three to a maximum dose of 20 mg). Data were collected on analgesic effectiveness, changes in vital signs, and patient reported side effects.

Results: The pain score fell by a mean of 4.29 and 3.49 in the rapid and cautious regimen groups respectively (difference = 0.79, 95% CI 0.09 to 1.5, p = 0.028). However, over half the patients in both groups continued to suffer significant pain on arrival at hospital. There were no significant changes in vital signs after nalbuphine, but there was a greater incidence of patient reported drowsiness in rapid regimen patients (42% compared with 21%, 95% CI = 6.96 to 34.12%, p = 0.003).

Conclusion: A rapid dosing regimen of nalbuphine using 10 mg increments is more effective than and equally as safe as a cautious regimen using 5 mg increments. Further research is required to determine if a maximum dose exceeding 20 mg would result in fewer patients continuing to suffer significant pain before arrival at hospital.

  • nalbuphine
  • paramedic
  • analgesia
  • ambulance
  • dosing regimen

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  • Funding: none.

  • Conflicts of interest: none declared.