Pain after injury or surgery is treated much differently around the world. In particular, the amount of opioids prescribed is much greater in the United States. Are patients in other countries suffering, or are patients in the United States being overexposed to habit-forming medication that is associated with an epidemic of misuse, overdose, and overdose-related death? A study of American and Dutch patients recovering from open reduction and internal fixation of an ankle fracture demonstrated that American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients after operative treatment of hip and ankle fractures (1). Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed opioids during hospitalization. After discharge, 77% of American and none of the Dutch patients were prescribed opioids. Among patients with ankle fracture, 98% of American and 64% of Dutch patients were prescribed opioids during hospitalization. After discharge, 82% of American patients and 6% of Dutch patients were prescribed opioids.
American patients are prescribed more opioid pain medication than Dutch patients after operative treatment of an ankle fracture, but it is possible that pain is undertreated in Dutch patients. Another study tested if there was a difference in pain and satisfaction with pain relief between Dutch and American patients after operative treatment of ankle fractures. Patients that did not use opioids and Dutch patients had less pain and equivalent satisfaction with pain relief compared to patients that used opioids and American patients respectively (2). Nationality was the best predictor of pain intensity on the first postoperative day. Opioid medication was the best predictor of greater pain at suture removal and decreased satisfaction with pain management. In conclusion, pain and satisfaction with pain relief are culturally-mediated. Patients in the Netherlands that use non-opioid pain medication report less pain and greater satisfaction with pain relief than patients managed with opioid pain medication.
Opioid pain medication is frequently given to patients recovering from a surgical procedure for an extremity fracture in spite of evidence that acetaminophen may be adequate. One study offered evidence to suggest that prescription of acetaminophen is not inferior compared with acetaminophen and tramadol in patients who underwent operative treatment for an extremity fracture (3). Given that tramadol has more side effects and is potentially habit-forming, acetaminophen should be considered the mainstay for pain relief in patients recovering from extremity fracture surgical procedures.
References
- Lindenhovius AL, Helmerhorst GT, Schnellen AC, Vrahas M, Ring D, Kloen P. Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands. J Trauma 2009; 67(1):160-4
- Helmerhorst GT, Lindenhovius AL, Vrahas M, Ring D, Kloen P. Satisfaction with pain relief after operative treatment of an ankle fracture. Injury. 2012 Nov;43(11):1958-61. doi: 10.1016/j.injury.2012.08.018. Epub 2012 Aug 16. PubMed PMID: 22901424.