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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
26th July 2021
Rheumatoid arthritis (RA) is an autoimmune disease that causes joint inflammation, pain, stiffness and destruction of articulator bone and cartilage that affects around 51/10,000 people. Treatment involves the use disease-modifying anti-rheumatic agents (DMARDs) but despite this, evidence suggests that patients continue to experience activity limitations and pain, despite reduced levels of inflammation. The persistence of pain has a negative impact on quality of life and leads to fatigue. In fact, it has been suggested that the extent of pain identified by patients at the point of diagnosis can predict the level of fatigue subsequently reported. Hence, a better understanding of the potential predictors of pain early in the disease course, could enable better targeting of pain interventions. In trying to identify the predictors of pain, a team from the Department of Clinical Sciences, Malmo, Lund University, Sweden, turned to data on an inception cohort of patients with RA, recruited between 1995 and 2005, who had been diagnosed with the condition for less than 12 months. A structured examination and data collection programme occurred at inception and then after 6 months, 1, 2 and 5 years. There was no specific treatment protocol and patients were all managed according to standard care. Patient reported outcomes and disease activity measures were collected at each follow-up visit and pain was assessed using a visual analogue scale (VAS), ranging from 0 to 100, with higher scores indicating more severe pain. In addition, a patient global assessment of disease activity (PGA) was included as were measures of swollen joint counts and various biological measures e.g., anti-CCP antibodies. For the purposes of the study, unacceptable pain was defined as a VAS scores > 40.
In total, 232 patients with early rheumatoid arthritis with a mean age of 60.5 years (70.3% female) were included in the analysis but only 179 attended the 5-year follow-up appointment. At inception, the mean VAS pain score was 41.2 and reduced to 32.3 at the first 6-month appointment but remained unchanged during the next five years. The proportion of patients with unacceptable pain scores at inception was 49.1% although this decreased to 30.1% during the first year. However, as with mean VAS scores, the proportion of patients with unacceptable pain did not alter over time. At the two-year follow-up, significant predictors of unacceptable pain included female sex (odds ratio, OR = 2.57, 95% CI 1.27–5.33) and VAS pain scores (OR = 1.56). After 5 years, 34.1% of patients still had unacceptable pain and significant predictors included lower swollen joint counts (OR = 0.71) and anti-CCP antibodies (OR = 0.50).
The authors noted that while RA patients had low inflammatory activity, a third continued to experience pain 5 years later. They concluded that future studies should focus on how to optimise pain management at an early disease stage because this was associated with a great burden over time.
Eberhard A et al. Predictors of unacceptable pain with and without low inflammation over 5 years in early rheumatoid arthritis — an inception cohort study. Arthritis Res Ther 2021