The management of pain following fractures is a critical aspect of patient care. While fracture care coding guidelines, such as those relevant in 2016, primarily focus on the accurate billing and classification of fracture treatments, they indirectly highlight the importance of comprehensive patient management, including pain control. This article delves into the best practices for opioid prescribing in the context of fracture care, drawing upon established recommendations for chronic pain management, and adapting them to the unique challenges of fracture-related pain.
I. Determining When to Initiate or Continue Opioids for Fracture Pain
1. Prioritizing Nonpharmacologic and Nonopioid Therapies (Recommendation Category: A, Evidence Type: 3)
For fracture pain, as with chronic pain, nonpharmacologic and nonopioid pharmacologic therapies should be the cornerstone of treatment. Opioid therapy should only be considered when the anticipated benefits for both pain relief and functional recovery clearly outweigh the risks. When opioids are deemed necessary, they must be used in conjunction with nonpharmacologic and nonopioid pharmacologic strategies.
Effective nonpharmacologic approaches for fracture recovery include physical therapy to restore mobility and strength, and psychological therapies to manage pain perception and improve coping mechanisms. Nonopioid medications such as acetaminophen and NSAIDs can effectively manage mild to moderate fracture pain, particularly in the acute phase. These options carry fewer risks of dependence and overdose compared to opioids.
Alt text: Recommendation emphasizing nonpharmacologic and nonopioid therapies as preferred for chronic pain management, applicable to fracture pain.
It’s crucial to remember that the goal is not just pain reduction, but also functional restoration. Encouraging active patient participation in rehabilitation, even with some pain, is vital for long-term recovery. Integrating exercise, even simple range-of-motion exercises as guided by a physical therapist, plays a significant role in healing and regaining function after a fracture.
2. Establishing Treatment Goals Before Starting Opioids (Recommendation Category: A, Evidence Type: 4)
Before initiating opioid therapy for fracture pain, clinicians must engage in a detailed discussion with patients to establish clear treatment goals. These goals should encompass realistic expectations for both pain relief and functional improvement. Furthermore, the conversation should proactively address a plan for opioid discontinuation if the therapy fails to provide sufficient benefits or if risks become predominant. Opioid therapy should only continue if there is demonstrable, clinically meaningful progress in pain and function that justifies the ongoing risks.
Alt text: Recommendation highlighting the importance of establishing treatment goals with patients before starting opioid therapy.
Given the potential for long-term opioid use to originate from acute pain management, setting these goals upfront is particularly important in fracture care. It’s crucial to define what “clinically meaningful improvement” looks like for each patient, which could involve returning to specific daily activities, improving mobility, or reducing pain to a tolerable level that allows participation in rehabilitation.
3. Discussing Risks and Benefits of Opioid Therapy (Recommendation Category: A, Evidence Type: 3)
Prior to initiating opioid therapy and periodically throughout its duration, clinicians must have an open and honest discussion with patients about the known risks and realistic benefits of opioid treatment. This discussion should also cover the shared responsibilities of both the patient and clinician in managing opioid therapy safely.
Alt text: Recommendation emphasizing the need for clinicians to discuss risks and benefits of opioid therapy with patients.
Patients need to be fully informed that while opioids can provide short-term pain relief, their long-term effectiveness for pain and functional improvement is uncertain. It’s essential to highlight the potential for serious harms, including opioid use disorder, overdose, and other adverse effects. Conversely, realistic benefits, such as initial pain reduction to facilitate early mobilization and physical therapy, should be clearly articulated. This informed consent process empowers patients to participate actively in their pain management plan.
II. Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation in Fracture Care
4. Starting with Immediate-Release Opioids (Recommendation Category: A, Evidence Type: 4)
When opioid therapy is initiated for fracture pain, immediate-release formulations are preferred over extended-release/long-acting (ER/LA) opioids. ER/LA opioids carry a higher risk of overdose, particularly when starting therapy. Immediate-release opioids provide more flexibility in dosing and are generally more appropriate for managing acute pain episodes associated with fractures and the recovery process.
Alt text: Recommendation favoring immediate-release opioids over ER/LA opioids when starting opioid therapy.
ER/LA opioids are typically reserved for chronic pain conditions requiring around-the-clock pain management, which is less frequently the case in fracture recovery, especially in the initial stages. Using immediate-release opioids allows for tailored dosing based on the fluctuating pain levels experienced during healing and rehabilitation.
5. Prescribing the Lowest Effective Dosage (Recommendation Category: A, Evidence Type: 3)
Opioids should always be prescribed at the lowest effective dosage to manage fracture pain. Caution is advised at any dosage, and careful reassessment of benefits and risks is crucial when considering increasing the dosage to ≥50 morphine milligram equivalents (MME)/day. Escalating dosages to ≥90 MME/day should be avoided unless there is a compelling clinical justification and rigorous assessment of individual patient needs.
Alt text: Recommendation advocating for prescribing the lowest effective dosage of opioids.
Higher opioid dosages are associated with increased risks of adverse events, including overdose and opioid use disorder, without necessarily providing superior pain relief or functional improvement, especially in the long term. In fracture care, managing pain effectively should be balanced against minimizing opioid exposure.
6. Limiting Opioid Duration for Acute Fracture Pain (Recommendation Category: A, Evidence Type: 4)
Long-term opioid use often begins with the treatment of acute pain. When opioids are used for acute fracture pain, clinicians should prescribe the lowest effective dose of immediate-release opioids for the shortest duration necessary. In many cases, three days or less will be sufficient, and more than seven days is rarely needed. This limited duration helps minimize the risk of developing physical dependence and transitioning to chronic opioid use.
Alt text: Recommendation for limiting the quantity of opioids prescribed to the expected duration of acute pain.
For most uncomplicated fractures, acute pain typically subsides significantly within a few days to a week. Prescribing opioids beyond this period for routine fracture pain management should be carefully reconsidered. If pain persists, re-evaluation of the fracture, potential complications, and alternative pain management strategies are essential.
7. Regular Evaluation of Benefits and Harms (Recommendation Category: A, Evidence Type: 4)
Within 1 to 4 weeks of initiating opioid therapy for fracture pain, or following any dose escalation, clinicians should evaluate the benefits and harms with their patients. Subsequently, ongoing therapy should be reassessed at least every 3 months. If the benefits of continued opioid therapy do not outweigh the harms, clinicians should optimize nonopioid therapies and work collaboratively with patients to taper and discontinue opioids.
Alt text: Recommendation for clinicians to evaluate benefits and harms of opioid therapy with patients within 1 to 4 weeks of initiation.
Regular follow-up is crucial to ensure that opioid therapy remains appropriate and effective. This includes assessing pain levels, functional progress, and any adverse effects or warning signs of opioid-related complications. If functional improvement is not evident or if risks outweigh benefits, a structured tapering plan should be implemented to minimize withdrawal symptoms and ensure patient safety.
III. Assessing Risk and Addressing Harms of Opioid Use in Fracture Patients
8. Evaluating Risk Factors for Opioid-Related Harms (Recommendation Category: A, Evidence Type: 4)
Before starting and periodically during opioid therapy, clinicians should evaluate individual risk factors for opioid-related harms. For fracture patients, this is particularly important as trauma and surgery can introduce unique vulnerabilities. Strategies to mitigate identified risks, including considering naloxone prescription in high-risk scenarios, should be integrated into the management plan. Risk factors can include pre-existing conditions, concurrent medications, and psychosocial factors.
Alt text: Recommendation for clinicians to evaluate risk factors for opioid-related harms before and during opioid therapy.
9. Utilizing Prescription Drug Monitoring Programs (PDMP) (Recommendation Category: A, Evidence Type: 4)
Clinicians should utilize state Prescription Drug Monitoring Program (PDMP) data to review a patient’s history of controlled substance prescriptions. This review should occur when initiating opioid therapy for fracture pain and periodically throughout its course, ranging from every prescription to every 3 months. PDMP data helps identify patients who may be receiving high opioid dosages or dangerous combinations from multiple prescribers, increasing their overdose risk.
Alt text: Recommendation for clinicians to review PDMP data to assess patient’s controlled substance prescription history.
10. Considering Urine Drug Testing (Recommendation Category: B, Evidence Type: 4)
Urine drug testing can be considered before starting opioid therapy and at least annually to assess for the presence of prescribed medications, other controlled prescription drugs, and illicit substances. While categorized as a Category B recommendation, indicating it may not be necessary for all patients, urine drug testing can provide valuable objective information, especially in patients with risk factors for substance misuse or when there are concerns about adherence to the prescribed regimen.
Alt text: Recommendation suggesting urine drug testing before starting and annually during opioid therapy.
11. Avoiding Concurrent Prescription of Benzodiazepines (Recommendation Category: A, Evidence Type: 3)
Whenever possible, clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently. This combination significantly elevates the risk of respiratory depression and fatal overdose due to the synergistic central nervous system depressant effects of both drug classes. In the context of fracture care, anxiety and sleep disturbances are common, but these should be managed with non-benzodiazepine alternatives and nonpharmacologic strategies.
Alt text: Recommendation against concurrent prescribing of opioids and benzodiazepines.
12. Offering Treatment for Opioid Use Disorder (Recommendation Category: A, Evidence Type: 2)
Clinicians must be prepared to offer or arrange evidence-based treatment for patients who develop opioid use disorder. This typically involves medication-assisted treatment with buprenorphine or methadone, combined with behavioral therapies. Early identification and intervention are critical to managing opioid use disorder effectively and improving patient outcomes. In fracture patients, recognizing signs of opioid use disorder is crucial, especially if opioid therapy extends beyond the acute pain phase.
Alt text: Recommendation for clinicians to offer or arrange evidence-based treatment for opioid use disorder.
Conclusion
Effective pain management is integral to fracture care, but it must be approached responsibly, particularly when considering opioid prescriptions. While fracture care coding guidelines in 2016 and beyond focus on accurate billing and service classification, the underlying principle remains patient-centered care. By adhering to best practices in opioid prescribing, prioritizing nonopioid and nonpharmacologic therapies, and diligently assessing and mitigating risks, clinicians can optimize pain relief and functional recovery for fracture patients while minimizing the potential harms associated with opioid use. This balanced approach ensures that pain management aligns with both clinical effectiveness and patient safety within the framework of comprehensive fracture care.
