Drug overdose deaths have become an epidemic in the United States. In the past 15 years, deaths related to drug overdoses in the United States have tripled, mostly because of the increase in opioid-related deaths.1,2 In the same period, almost half a million people have died of prescription drug overdoses.1,2 Opioids, including prescription drugs and heroin, are involved in 61% of drug overdose deaths.3 The rate of increase in deaths from commonly prescribed opioids has slowed slightly in the past few years, whereas death rates from the synthetic opioids fentanyl and heroin have increased by 72% and 21%, respectively.3 This epidemic has taken a significant toll on the health of the nation, with emerging findings that opioid-related deaths have led to a 0.21-year reduction in average life expectancy—contributing to the overall decrease in life expectancy from 2014 to 2015.4
The increase in opioid overdose deaths aligns with a proportional increase in opioid prescribing rates. Opioid prescriptions increased substantially from 2006 to 20125 with a desired focus on treating patient pain. Family medicine physicians overall provide the most opioids of any specialty; however, orthopaedic surgeons prescribe 7.7% of prescriptions despite representing only 2.5% of physicians.6 The increase in opioid prescriptions was unfortunately not associated with the anticipated reduction of reported pain among Americans.7 Without an improvement in patient outcomes, these prescriptions are needlessly associated with a high risk of abuse. Adding to the problem of oversupply for needs, many opioids go unused following orthopaedic surgery,8,9 creating the possibility of nonmedical usage or diversion. Furthermore, of the patients who receive a first opioid prescription of any duration, 21% progress to receiving more prescriptions episodically and 6% progress to long-term use.10 Up to half of patients who take opioids for at least 3 months remain on opioids 5 years later and are likely to become lifelong users.11–13 Therefore, changing prescribing habits has been a high priority.
Because of the increasing recognition of the opioid crisis, several professional societies, health care systems, pharmacies, insurance companies, and governmental organizations have released guidelines and toolkits for the safe prescribing of opioids. Although some of these guidelines address certain aspects of pain from musculoskeletal conditions, many are focused on the management of chronic pain, and unfortunately, few give concrete examples of practical methods and prescribing practices that can be easily implemented when caring for acute musculoskeletal injuries. Thus, we aimed to produce comprehensive guidelines and recommendations that can be used by orthopaedic practices and other specialties to improve the management of acute pain following musculoskeletal injury.
This guideline aims to provide evidence-based recommendations for the management of acute musculoskeletal pain. A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. Chronic pain is outside the scope of this guideline.
The panel met in person in October 2017 to define the scope of the guideline and identify important topics for inclusion. The topics included cognitive strategies, physical modalities, opioid safety and effectiveness, multimodal pharmaceutical strategies, medical assistance therapy, nonsteroidal anti-inflammatory drugs and fracture healing, nerve/regional/field blocks, pain and sedation assessment strategies, and health care system strategies. One or 2 panel members were assigned to draft recommendations for each topic area. Literature searches were conducted through September 2018.
The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation.14 This method yields a grade for the strength of the recommendation and a grade for the quality of the evidence. The grading of the evidence was based on the study designs, number of studies, sample sizes, and consistency of results among different studies. The panel assigned recommendations as “strong” (practices in which benefits are sure to outweigh potential harms) or “conditional” (the evidence was weaker or if the benefits do not significantly outweigh potential harms).
Recommendations from each topic area were combined to produce a comprehensive guideline for management of acute musculoskeletal pain. All panel members reviewed and revised the combined guideline. The guideline was submitted to the Orthopaedic Trauma Association for review and was approved on October 16, 2018.
Because of the increasing recognition of the opioid crisis, several professional societies, health care systems, pharmacies, insurance companies, and governmental organizations have released guidelines and toolkits for the safe prescribing of opioids.3,15–39 Although some of these guidelines address certain aspects of pain from musculoskeletal conditions, many are focused on the management of chronic pain, and few give concrete examples of practical methods and prescribing practices that can be easily implemented when caring for acute musculoskeletal injuries.
We provide best practice recommendations and pain medication recommendations (Tables 1–4) with the hope that they can be used by orthopaedic practices and other specialties (eg, primary care and emergency medicine) to improve the management of acute pain following musculoskeletal injury. The best practice recommendations for acute pain management following musculoskeletal injury are supplemented with the corresponding in-depth reviews presented in this article. The pain medication recommendations are divided into 3 clinical scenarios—major musculoskeletal injury procedure (eg, operative fixation of long bone or complex joint fracture, extensive soft tissue injury or surgery, etc.), minor musculoskeletal injury procedure (eg, operative fixation of small bone or simple joint fracture, minimal soft tissue dissection or surgery, etc.), and nonoperative musculoskeletal injury (eg, closed management of injury, laceration repair, etc.). The best practice recommendations and the pain management recommendations are meant to be used in conjunction with each other and should be individualized per treating physician discretion according to patient characteristics, local practice preferences, and applicable state laws.Nociception is the physiology of actual or potential tissue damage. Pain is the unpleasant thoughts, emotions, and behaviors that accompany nociception. There is wide variation in pain intensity for a given nociception.40 Pain catastrophizing is an ineffective coping strategy characterized by unhelpful preparation for the worst including rumination and helplessness.41 Greater catastrophic thinking is consistently associated with greater pain intensity.42 Increased symptoms of anxiety and depression and greater alcohol use are also associated with higher pain intensity, whereas self-efficacy and fewer symptoms of depression are associated with less pain.
Studies of musculoskeletal injuries, including ankle sprains and fractures, have found no association between pain intensity and degree of nociception (injury severity). Variations in pain intensity and magnitude of limitations are accounted for more by measures of psychosocial aspects of illness than by measures of pathophysiology.44,46–53
A notable portion of trauma patients have substantial symptoms of anxiety, depression, and post-traumatic stress disorder months after injury. Giving opioids for pain that is more intense and disabling than expected might represent a misdiagnosis and mistreatment of stress, distress, and less effective coping strategies.
Initial studies of psychosocial interventions to limit psychological distress and improve comfort and ability have had mixed results.62,79–94 The goals of these interventions are to improve overall mental health and decrease rates and severity of depression, anxiety, and posttraumatic stress disorder. Interventions studied include cognitive behavior therapy, self-management interventions and training, educational information access, peer support, and online social networking. Cognitive behavioral interventions have positive effects on pain relief in some trials.58,95,96 There is also evidence that web-based cognitive behavioral therapy is effective.97–99 Meta-analyses of music therapy demonstrate decreased anxiety and better sleep in the setting of chronic medical illness.100 Music therapy has also demonstrated positive effects on pain relief and opioid dose reduction. Similarly, systematic reviews of aromatherapy have demonstrated anxiolytic effects101 and pain reduction.102 Further research on the utility of various interventions can help elucidate the most effective resources for trauma patients.
Cryotherapy is the application of an external cold source in which the desired effect is a drop in tissue temperature. Cold sources that have historically been used include ice bags, cold gel packs, ice massage, cold water submersion, gaseous cryotherapy, and continuous-flow cryotherapy devices with and without pneumatic compression. Basic science studies have shown that the biologic effects of cold therapies are multifactorial. A decrease in tissue temperature results in decreased tissue edema and microvascular permeability,111,112 reduced delivery of inflammatory mediators,112–116 reduced blood flow via vasoconstriction,116–120 overall net decrease in tissue metabolic demand, and subsequent hypoxic injury.116–118,120 In addition, the decrease in tissue temperature has been shown to increase the threshold of painful stimuli and increase the tolerance to pain.
Balancing comfort and patient safety following acute musculoskeletal injury is possible when using a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this document, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and nonoperative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.
Leave a comment
You must be logged in to post a comment.