PAIN MANAGEMENT AFTER ORTHOPEDIC TRAUMA
Orthopedic trauma, i.e. fractures of bones, is very painful. Opioids like hydrocodone and oxycodone have been used for pain control for decades with mixed results—they help sometimes, but they also have troublesome side effects and lead to drug dependence. Fractures take months to heal and pain is slow to resolve so there exists the potential for a patients to develop physical dependence on opioids. As the pain persists, the dose required for pain relief gradually increases. When the patient tries to stop the opioid, or doesn’t take it for awhile, serious, bothersome withdrawal effects occur, and the patient must take the opioid to prevent those unpleasant symptoms. That’s called opioid dependence, and it’s a major problem in the US.
Recently, however, new guidelines and recommendations for traumatic pain control have been published by the Eastern Association for the Surgery of Trauma and The Orthopedic Trauma Association. These new guidelines promote the use of Non-steroidal Anti-inflammatory Drugs (NSAID’s) for post-traumatic pain. Opioid abuse and misuse have become such a serious problem that NSAID’s, despite GI bleeding concerns, are now preferred.
NSAID’s provide adequate pain control without the concern for opioid dependence. NSAID’s like ibuprofen and naproxen are not without problems, but drug dependence is not one of them. When dosed adequately, NSAID’s provide a comparable degree of pain relief for orthopedic fractures in adults without the concern for opioid dependence.
A major concern among orthopedists is that both opioids and NSAID’s can cause delayed healing, or even non-healing (non-union), of the fracture. Non-union of a fracture is a disastrous problem that must be avoided, but NSAID’s have a very low incidence of non-union and thus, are the preferred choice for post-traumatic pain. NSAID’s have lasting effect, and unlike opioids, doctors don’t need to increase the dose to keep the patient comfortable.
In the acute care setting (the ER), intravenous ketorolac (Toradol) is given for traumatic fractures and has provided good relief and reduced the need for opioids.
The “take home message” here is that non-steroidal anti-inflammatory drugs (ibuprofen, naproxen), given orally or IV, provide equal, or even superior, pain relief for orthopedic fractures in elderly Americans when compared to opioids, without the concern for drug dependence or non-union of the fracture. Two large groups of orthopedic and trauma surgeons have endorsed this policy and have recommend it for their practitioners.
One must also remember NSAID’s are very effective for relieving the pain of a wide range of problems and are the standard of care for post joint replacement procedures.
References: Practice Guidelines—Pain Management After Orthopedic Trauma: Guidelines from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association Am Fam Phys 2024 April;109(4):376-377.
