Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief.

BACKGROUND: In 2012, Medicare began to tie reimbursements to inpatient complications, unplanned readmissions, and patient satisfaction, including satisfaction with pain management. QUESTIONS/PURPOSES: We aimed to identify factors that correlate with (1) pain intensity during a 24-hour period after surgery; (2) less than complete satisfaction with pain control; (3) less than complete satisfaction with staff attention to pain relief while in the hospital; and we also wished (4) to compare inpatient and discharge satisfaction scores. METHODS: Ninety-seven inpatients completed measures of pain intensity (numeric rating scale), satisfaction with pain relief, self-efficacy when in pain, and symptoms of depression days after operative fracture repair. The amount of opioid used in oral morphine equivalents taken during the prior 24 hours was calculated. Through initial bivariate and then multivariate analysis, we identified factors that were associated with pain intensity, less than complete satisfaction with pain control, and less than complete satisfaction with staff attention to pain relief. RESULTS: Patients who took more opioids reported greater pain intensity (r = 0.38). No factors representative of greater nociception (fracture type, number of fractures, days from injury to surgery, days from surgery to enrollment, or type of surgery) correlated with greater pain intensity. The best multivariable model for greater pain intensity included: depression or anxiety disorder (p = 0.019), smoking (0.047), and greater opioid intake (p = 0.001). Multivariable analysis for less than ideal satisfaction with pain control included the Pain Self-Efficacy Questionnaire (PSEQ) (odds ratio [OR], 0.95; 95% CI, 0.92-0.99) alone; for less than ideal satisfaction with staff attention to pain control, the PSEQ (OR, 0.96; 95% CI, 0.92-0.99) and opioid medication use before admission (OR, 3.6; 95% CI, 1.1-12) were included. CONCLUSIONS: After operative fracture treatment, patients who take more opioids report greater pain intensity and less satisfaction with pain relief. Greater self-efficacy was the best determinant of satisfaction with pain relief. Evidence-based interventions to increase self-efficacy merit additional study for the management of postoperative pain during recovery from a fracture. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

The future of topical analgesics.

Topically applied analgesic therapies have been used throughout history to treat a variety of patient conditions that present with pain. Before modem pharmaceuticals became readily available, mud-based emollients, salves, cold therapies, and other natural remedies were often used. Now we have effective therapies and are developing advanced topical analgesics as we learn more about the physiology and pathophysiology of pain. The use of topical analgesics may be associated with fewer patient systemic side effects than are seen with oral, parenteral, or transdermally administered agents, making the topical route of administration attractive to prescribers and patients. With further refinement of existing drugs and the development of novel agents, topical analgesics may offer relief for treating patient pain conditions that are currently challenging to treat, such as pain resulting from burns, wound debridement, and pressure ulcers. Recognizing the value of a multimodal approach, topical analgesics may offer a therapeutic option that can become part of a comprehensive treatment plan for the patient. With continued advancements in targeted drug-delivery systems, topical analgesics may be able to provide a method to prevent or reverse the phenomena of peripheral and central sensitization, or the neuroplastic changes believed to be responsible for the transition from acute to chronic pain states in patients. For those patients at risk for developing chronic pain states, such as complex regional pain syndrome, the combination of cutaneous stimulation (achieved through rubbing during application) and analgesic effects produced by the drug itself may prevent the disabling pain that often emerges during the subacute phase of disease. In summary, better utilization of currently available topical analgesics and continued research promise to ensure that topical analgesics are, and will continue to be, important tools in the treatment of patients with resistant pain.

Evolution of topical NSAIDs in the guidelines for treatment of osteoarthritis in elderly patients.

Increasing age is the primary predictor of osteoarthritis, the most prevalent painful condition in the US. Because there are no disease-modifying therapies for osteoarthritis, relief of symptoms and maintenance of quality of life through improving joint function become the focus of management. Although highly effective for pain relief, oral nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with systemic adverse reactions that are sometimes treatment limiting, especially for older patients. Thus, osteoarthritis management in elderly populations is shifting away from traditional NSAIDs to therapies that provide comparable pain relief with improved safety. Since the approval by the US Food and Drug Administration of the use of topical NSAIDs to manage osteoarthritis pain, current treatment guidelines put forth by several professional societies have begun to recommend topical NSAIDs as an alternative therapy and, most recently, as first-line therapy for osteoarthritis management in the elderly. This review provides an overview of the various treatment guidelines that are available to assist prescribers in making safe and effective decisions in the treatment of osteoarthritis in this high-risk patient population.