Medical Technology

Strong Opioids Not Required After Fracture Surgery

A recent study published in JAMA Open has shown that Oxycodone doesn’t provide relief from pain after a surgery for fractures, more so than acetaminophen with codeine.

Investigators from a major trauma hospital in Sydney, Australia conducted a double-blind clinical trial, randomized clinical trial of pain medication for patients who had surgery for fractures. The 120 patients were provided with oxycodone during hospitalization and a sealed medication packet upon discharge. The packages contained immediate-release oxycodone or acetaminophen, and codeine.

Despite oxycodone having six times the amount of opioid and a lower dose of opioids, there were no significant differences in the number of pain scores within the first seven days following the discharge. The mean daily numerical pain scores were 4.04 (95 percent Cl, 3.67 – 4.41) in the group with strong-opioid effects and 4.54 (95 percent Cl, 4.17 – 4.90) in the mild-opioid category. The primary difference in outcome between the groups was not statistically significant (-0.50, 95% Cl. -1.11 to 0.12] P =.11).

Ian Harris

Study investigator Ian Harris, MBBS, FRACS Professor of orthopedic surgery at the University of New South Wales in Sydney, was concerned that patients were discharged on strong opioids that have the potential to lead to addiction.

“Strong opioids have strong adverse effects and are not as effective as we think,” he told Medscape Medical News. “Most times, something less harmful is just as good.”

Harris’s experience of seeing patients become dependent on opioids and previous trials questioning the effectiveness of strong opioids led Harris to the conclusion that a randomised and blinded study was warranted.

From his point of view Harris believes that the illicit opioid pill issue is as significant in Australia as it is in the United States. Its trauma population does not typically include those abusing substances or taking pain medications for chronic pain. He doesn’t believe that addicts are buying the opioids illegally. He is more concerned that opioids are being prescribed by general practitioners to patients three or more months following surgery.

He wants patients and all physicians to know that “studies have shown that safer medicines are just as effective.” We should also be honest with patients. Although some pain is normal after surgery however, there are other ways to manage it.

Robert Zura

Robert D. Zura MD chair of orthopaedics at LSU Health Sciences Center, New Orleans, was not involved in the study but expressed his appreciation to the researchers for their great work. “I’m glad that they are conducting this important research. The opioid epidemic is alarming in its impact on our patients.”

He believes this study will encourage clinicians to ensure safety while ensuring pain control for patients. He would like to see more standard protocols being developed on an international scale. He said, “Hopefully, we are able to proceed with the largest-scale multinational research and come up with an universal protocol that is able to balance safety and pain control as well as patient satisfaction and speedy return-to-function.”

Zura warns that despite all of this information, it can be difficult to talk with patients about pain control and medications following an orthopedic surgery. There are “so many variables that there are a lot of preconceived notions, and sometimes addictions,” he told Medscape Medical News. Research suggests that close to 15% of LSU’s trauma patients are admitted to the hospital due to chronic opioids.

Kanu Okike

Kanu Okike, MD, MPH, an orthopedic surgeon with Kaiser Permanente in Honolulu, who was not part of the study, also commended the researchers for their research. “Conducting controlled, randomized studies in the field orthopedic surgery is always challenging and the investigators deserve to be applauded.

He stated that Hawaii is unique in that its consumption of opioids is much lower than the rest of the United States. Medscape Medical News. “Nevertheless many patients who undergo orthopedic trauma surgery are discharged from hospitals with Oxycodone.” The results of this study suggest that an opioid that is milder might be enough to treat the patient, he added.

He does take pause regarding codeine. “Codeine is a pre-metabolizer for drugs that is metabolized into its active form by the patient following it is taken. The process of metabolization is different for every patient. Codeine can cause excessive or inadequate activity depending on the patient.

He has seen acetaminophen and codeine fall out of favor in the United States. “Nevertheless, the point that a mild opioid can offer the same pain relief as a powerful opioid is valid,” he concluded.

Harris, Zura, Okike and Okike did not disclose any financial relationships of the relevant nature.

JAMANetw Open. 2021;4(11):e2134988. Full Text

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