Greater Opioid Intake After Ankle Fracture Linked to Increased Pain

Past studies demonstrate that patients who use greater amounts of opioid medication after fracture surgery have greater pain intensity and less satisfaction with pain management. Massachusetts General Hospital researchers, led by principal investigator Marilyn Heng, MD, MPH, FRCSC, were curious if the same results held true after ankle fracture surgery. According to their study published in the Journal of the American Academy of Orthopaedic Surgeons, they found no association between the amount of opioid use and postoperative disability in this group, and at suture removal, pain scores were higher in patients using greater amounts of opioid medication.

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Researchers prospectively investigated the effect of opioid intake after open reduction and internal fixation of an ankle fracture. Between February 2012 and February 2014, they enrolled 102 adult patients at the time of suture removal, within four weeks of injury. Of the 99 patients with complete data, 52% were women, and the median age was 45 years (range 18–81 years).

Opioid intake was measured as oral morphine equivalent (OME), calculated from the types of pain medications and the number of pills the patients took. Altogether, 84% of the patients were using opioids (median 15 OME/day) at the time of suture removal.

The study’s primary outcome measure was the magnitude of disability using the Foot and Ankle Ability Measurement (FAAM) score at suture removal. Patients also completed the Pain Anxiety Symptoms Scale short version, the Pain Catastrophizing Scale, the Patient Health Questionnaire-2 (PHQ-2) and 11-point numeric scales to rate their pain at rest, pain with activity, satisfaction with pain management and overall treatment satisfaction.

Approximately five to eight months after suture removal (average of 202 days), a research assistant contacted 59 of the patients. Fourteen of them—nearly one-quarter—said they were still using opioids. The assistant also recorded scores on the FAAM, the PHQ-2 and the numeric rating scales.

Opioids performed poorly at reducing postoperative disability. The researchers report that psychological factors, not opioid use, determined the magnitude of postoperative disability. Upon multivariate analysis, decreased disability at suture removal was not independently associated with opioid intake, but it was associated with less catastrophic thinking, among other variables. In this context, the researchers explain that catastrophic thinking is the tendency to misinterpret or overinterpret pain as damage or doom.

At five to eight months after suture removal, decreased disability was only associated with lower anxiety about pain at the time of suture removal.

Opioids also performed poorly with regard to pain relief. At suture removal, both greater pain at rest and greater pain with activity were associated with more opioid use and more catastrophic thinking. At follow-up, neither of these types of pain were associated with opioid use, but greater pain with activity was associated with more catastrophic thinking.

Opioid intake was not found to be associated with treatment satisfaction, or satisfaction with pain management, at either time point. Rather, at suture removal, both greater satisfaction measures were associated with less catastrophic thinking.

The researchers urge orthopedics clinics to move away from the opioid-centric model of pain management in favor of a more comprehensive approach. That would include optimizing the patient’s mindset and circumstances, particularly by addressing stress, distress and ineffective coping strategies. Physical strategies such as elevation and ice also should have a prominent role.

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