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Can It Be Done—Opioid-Free Recovery?

Commentary on an article by Gijs T.T. Helmerhorst, MD, et al.: “Pain Relief After Operative Treatment of an Extremity Fracture: A Noninferiority Randomized Controlled Trial”

Shilling, Ashley MDa

doi: 10.2106/JBJS.17.00856
Commentary and Perspective
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University of Virginia, Charlottesville, Virginia

aE-mail address for A. Shilling:

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This article by Helmerhorst et al. is a timely one, as the opioid crisis has hit catastrophic heights. With 92 Americans dying every day from opioid overdose, improved prescribing by health-care providers is critical1. In this prospective study performed in the Netherlands, 52 patients undergoing a surgical procedure for an extremity fracture were randomized to receive either acetaminophen or acetaminophen with tramadol for breakthrough pain after discharge from the hospital. Patients in both groups were also allowed to take diclofenac every 8 hours for breakthrough pain and ultimately could call their surgical clinic for an oxycodone prescription as a final rescue medication. The authors’ primary outcome was patient satisfaction with pain, and they used a noninferiority model for data analysis. Additionally, the authors sought, through multivariable analysis, to link various patient demographic characteristics and psychological questionnaire findings to pain perception or satisfaction.

The authors found a mean pain satisfaction score of 8.3 for the acetaminophen group and 8.5 for the acetaminophen with tramadol group, with significantly more patients receiving acetaminophen with tramadol experiencing adverse events. The authors did not report the number of pain pills taken during the postoperative period and noted only binary findings of use or no use for the various medication classes. It is notable that 9 patients in the group receiving the tramadol prescription actually used only acetaminophen, and 2 patients in the acetaminophen-only group required oxycodone.

A number of factors deem this study somewhat difficult to interpret. Tracking quantities of opioids used and a better standardization of protocol for the various medications, dosing, and timing of these could help us to better elucidate the pain medications used for patients with fracture and to better interpret the study results. Also, the study is powered with only 52 patients who underwent a huge range of surgical procedures. Included were surgical procedures ranging from simple hand fractures to humeral, pelvic, and hip fractures. Although the authors divide the fractures into large and small, it is difficult to draw conclusions and make comparisons between a patient with a hip or pelvic fracture and a patient with a wrist fracture. The conclusion, “acetaminophen should be considered the mainstay for pain relief in patients recovering from extremity fracture surgical procedures,” is a bold one and this conclusion reverts to the one-size-fits-all pain prescribing that led us to the opioid-prescribing dilemma in the first place. Indeed, not all fractures or patients are alike. Although we are wrong to believe that all surgical patients require narcotics, generalizing that acetaminophen should be the mainstay of treatment for all types of fractures may also be unfair. Opioid-naïve patients compared with opioid-tolerant patients, type and severity of fractures, potential for regional techniques, concerns for healing, and risks of nonsteroidal medications should all be considered when treating an individual patient.

The authors’ conclusion of acetaminophen for the mainstay of pain relief in patients recovering from extremity fracture is also an ambitious one, particularly in the United States, where patients frequently expect and are written narcotic prescriptions for surgical procedures as minimally invasive as a ganglion cyst resection. The authors are correct in noting the emotional dependence that patients have on opioids. I commend their description of the strong relationship among pain, emotions, and psychosocial variables. Better understanding factors that increase pain perception and decrease satisfaction is vital to understanding how best to manage patients. Additionally, patients must have realistic pain expectations and accountability for their postoperative course. Recent studies have demonstrated that patients prescribed even short-term opioids following a surgical procedure are at increased risk of chronic opioid use compared with patients who have never used opioids2.

A major strength of this article is the authors’ review of the literature, which is lacking evidence that opioids actually improve orthopaedic patient satisfaction. This article serves as an impetus for further prospective, randomized studies on exactly this issue. In 2016, a multidisciplinary expert panel conducted a systematic review of evidence and published 32 recommendations on the management of postoperative pain3. A mainstay of these recommendations includes multimodal analgesic techniques: acetaminophen, with or without nonsteroidal anti-inflammatory drugs, and the use of regional techniques when surgical procedures are amenable.

Although there are robust data on opioid risks, further studies tracking patients post-discharge are warranted to determine ideal analgesic regimens. I commend the authors and am hopeful that studies such as this can reform our prescribing patterns and can benefit patients throughout the world, with not only better satisfaction, but also improved safety, recovery, and quality of care.

Disclosure: There was no source of external funding for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (

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1. Centers for Disease Control and Prevention. Opioid overdose: opioid basics: understanding the epidemic. Drug overdose deaths in the United States continue to increase in 2015. 2016 Dec 16. Accessed 2017 Aug 2.
2. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016 Sep 1;176(9):1286-93.
3. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, Carter T, Cassidy CL, Chittenden EH, Degenhardt E, Griffith S, Manworren R, McCarberg B, Montgomery R, Murphy J, Perkal MF, Suresh S, Sluka K, Strassels S, Thirlby R, Viscusi E, Walco GA, Warner L, Weisman SJ, Wu CL. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016 Feb;17(2):131-57.

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