What opioid-sparing pain medication that preserves bone healing should be prescribed for patients with fractures?
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Collective, organization-wide strategy
Nociception is the pathophysiology of actual or potential tissue damage. Pain is the unpleasant thoughts, emotions and behaviors that can accompany nociception. There is wide variation in pain intensity for a given nociception. A large part of this variation is accounted for by mental and social health.
In The Netherlands, people are comfortable with acetaminophen alone after ankle fracture surgery. Patients in the United States often have large numbers of unused pills after injury or surgery. Among inpatients recovering from fracture surgery, greater use of opioids inpatient is associated with less effective cognitive coping strategies and greater symptoms of depression. A request for opioids after fracture healing is associated with notable levels of psychological distress.
Armed with these facts, the AAOS Patient Safety Committee recommends a collective, organization-wide strategy that incorporates effective strategies for alleviation of pain and optimal opioid stewardship. Such a strategy moves discussions about limiting opioids from the personal to the collective and allows the physician to say: “We are not allowed to use opioids for this, so let’s talk about what we can do to get you comfortable.”
Opioids are habit forming and risky (respiratory suppression). The optimal amount of opioids is the fewest number of pills at the smallest dose for the shortest time possible. Opioids are not used for most nonoperatively treated fractures. After surgery, opioids can be limited to just a few days and mostly for sleep. I have no concern about using NSAIDs for fractures.
- American Academy of Orthopaedic Surgeons Pain Relief Toolkit. Available at: https://aaos.org/quality/painrelieftoolkit/. Accessed April 19, 2019.
David C. Ring, MD, PhD, is the associate dean of comprehensive care and professor of surgery and psychiatry at Dell Medical School, The University of Texas at Austin, and an Orthopedics Today Editorial Board Member.
Disclosure: Ring reports he is chair of the AAOS Patient Safety Committee.
Multimodal analgesia has synergistic effects
The best pain medication to prescribe for patients with fractures that is opioid-sparing begins with informed consent, health care provider and patient education, management of pain medicine expectations and implementation of an enhanced recovery after surgery model; then prescribing a deliberate perioperative and “multimodal” pain medication regime. “Balanced analgesia” prescriptions and adjuncts include local anesthetics, acetaminophen, selective COX-2 inhibitors, gabapentinoids, NSAIDs, steroids, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, N-methyl-D-aspartate receptor antagonists, alpha-2 agonists, physical and behavioral health interventions.
Post-surgical pain for surgical patients is traditionally managed with narcotic medications and prescription opioids. This practice has been linked to persistent opioid use and misuse along with administration for months or longer following surgery. Over-reliance on unimodal narcotic use for pain therapy and prescribing of opioids can have far-reaching unfavorable and deleterious consequences, may increase the likelihood of opioid diversion and misuse, and can lead to abuse/addiction in the home and community.
Multimodal analgesia combines medications from two or more classes or analgesic techniques that employ different mechanisms of action, can achieve synergistic effects, target different (peripheral or central) pain pathways, lower analgesic doses, reduces opioid reliance, minimize medication adverse events and minimizes sensitization. The synergy created with multimodal regimens targets discrete components of both peripheral and central pain pathways, provides effective analgesia and can lower/eliminate opioid rescue requirements.
Thomas Halaszynski, DMD, MD, MBA, is a professor of anesthesiology at Yale University School of Medicine in New Haven, Connecticut.
Disclosure: Halaszynski reports no relevant financial disclosures.