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23rd November 2021
Using strong opiates does not appear to provide superior post-discharge pain relief to patients after fracture surgical treatment. This was the main conclusion of a study by a team from the Daffodil Centre, University of Sydney, Australia.
Although opiates are recognised as being effective for the management of acute pain, such drugs are not always required and in some instances may create more risks than benefits to patients. Moreover, some data suggests that for every additional week of post-surgical opiate use, there is a 44% increased risk of misuse.
Given this potential for misuse, the Australian researchers undertook a randomised, double-blind, clinical trial to compare the effect on pain management of strong opiates to a combination of paracetamol and codeine, a weak opiate. They included patients who were admitted to a major trauma hospital with at least one acute fracture of a long bone, e.g., the humerus, radius, ulna, femur, tibia or fibula, that required surgical management. Patients were then randomised 1:1, to receive either oxycodone hydrochloride 5 mg or 10 mg or paracetamol and codeine (500 mg paracetamol and either 8 or 16 mg of codeine) for a maximum duration of three weeks although the doses were titrated downwards in the final week. Data was collected on days 3, 7, 14 and 21 after discharge and the primary outcome was pain as measured by the numerical pain rating scale (NRS), which ranges from 0 to 10, with the highest score (10) indicating the worst pain imaginable. For the purposes of the study the mean of the daily pain score from day 1 to 7 was calculated.
In total, 120 patients, 59 given strong opiates (oxycodone) were included in the study. The mean of the two groups were similar (36 years vs 38.2 years, oxycodone vs paracetamol/codeine) with slightly more women (27%) given oxycodone than paracetamol/codeine (23%). The mean daily NRS scores were 4.04 (95% CI 3.67 – 4.41) for oxycodone and 4.54 (95% CI 4.17 – 4.90) for paracetamol and codeine. The difference between the two groups between days 1 and 7 in pain scores was -0.50 (95% CI -1.11 to 0.12, p = 0.11). There was also no significant difference in daily tablet use between the two groups between days 1 – 7 and 1 – 21.
The authors commented on how there were no apparent differences in discharge pain scores between strong opiates and the combination of paracetamol and a weak opiate, despite oxycodone delivering a 6-fold higher dose of opiate. They concluded that given the lack of difference in pain relief, stronger opiates after discharge from hospital after an orthopaedic fracture should not be supported.
Jenkin DE et al. Effectiveness of Oxycodone Hydrochloride (Strong Opioid) vs Combination Acetaminophen and Codeine (Mild Opioid) for Subacute Pain After Fractures Managed Surgically: A Randomized Clinical Trial. JAMA Netw Open 2021