Strong opioids not better than milder painkillers after surgery for fractures, study finds
Strong opioids might not provide better pain relief than milder painkillers after surgery to treat bone fractures, new research suggests.
An Australian study of 120 patients undergoing surgery for orthopaedic fractures compared pain relief in the first week after patients were discharged from hospital.
The patients had all undergone orthopaedic surgery at a Sydney hospital to treat one or more fractures, such as in bones of the hip or leg.
The study found prescription oxycodone hydrochloride tablets did not provide superior pain relief compared with a combination of paracetamol and codeine, “despite a six-fold higher dose of opioid being delivered”.
The researchers concluded that “ongoing strong opioid use after discharge from the hospital should not be supported”.
The study’s lead author, Dr Deanne Jenkin of the Daffodil Centre – a joint venture of Cancer Council New South Wales and the University of Sydney – said: “Patients with surgically managed fractures are commonly, if not routinely, discharged home from hospital with a strong opioid prescription in Australia.”
Patients discharged from hospital with strong opioids reported an average pain score of 4.04 out of 10, where 10 represented the worst pain imaginable. Those discharged on paracetamol and codeine had a score of 4.54 – a difference the study’s authors found was not statistically significant.
“Clinicians should consider a less-ismore-approach for pain management upon hospital discharge following fracture surgery,” Jenkin said.
“It makes good sense to avoid medications that can cause harm if they provide no greater benefit as was the case here – no better pain outcomes for the strong opioid group.”
Dr Mick Vagg, dean of the faculty of pain medicine at the Australian and New Zealand College of Anaesthetists, who was not involved in the study, said: “It may well be possible to get people just as good pain relief without having to use strong opioids for all that long after the surgery.”
Sign up to receive an email with the top stories from Guardian Australia every morning
Vagg, who is also an associate professor at Deakin University, added: “One of the reasons why this study is important … is because the transition from in-hospital to out-of-hospital care is emerging as a key time when people may slip through the cracks and not be taken off [an] opioid when it’s not particularly helpful any more.”
“In Australia, it’s something like a quarter of people who are long-term prescription opioid users … they came into hospital for an operation, not on opioids, and they left [on a prescription] and never came off them.”
The prescription of opioids has increased significantly in Australia in recent decades. Close to 15.5 million opioid prescriptions were dispensed through the Pharmaceutical Benefits Scheme in 2016-17 – a figure not including codeine, which was available over the counter until 2018.
According to the Therapeutic Goods Administration, prescription opioids are now “responsible for far more deaths and poisoning hospitalisations in Australia than illegal opioids such as heroin”, with an estimated 150 hospitalisations daily.
Dr Pene Wood, anadjunct lecturer of pharmacy at Latrobe University, said there were no standardised statewide guidelines for how to manage hospital patients being discharged with opioids after surgery. “It would be nice for the state or a pain society … to provide something like that so it’s universal across the health sector.” In Wood’s experience, some patients have been discharged on higher doses of opioids than they were taking while in hospital.
Vagg said the research highlighted the importance of tailoring post-operative pain relief. “The old box of 20 Endone [a brand name for oxycodone hydrochloride] as you’re going out the door really doesn’t tend to be a very well targeted way of managing people’s pain.”
Wood agreed: “I think we need to really assess it on an individual basis.”
One limitation of the study, Vagg said, was the comparison of oxycodone with codeine, “which they call a mild opioid. I would have some disagreement with that characterisation.
“Codeine is a problematic opioid from a number of points of view,” he said.
Once ingested, codeine is metabolised into morphine, which acts on μ-opioid receptors to relieve pain. But there are significant genetic differences in how people’s bodies metabolise the drug.
“In about 10% of the Australian population … none of that codeine gets turned into morphine and they don’t get pain relief at all,” Vagg said. On the other end of the spectrum, there are ultra-rapid metabolisers who can experience intense side-effects from the drug.
“Only about 50% of the individuals in the Australian population have average metabolism of codeine,” Vagg said.
The research was published in the peer-reviewed journal JAMA Network Open.