A 45-year-old gentleman was admitted to hospital with a fractured tibial plateau following a road traffic collision. He was admitted under the orthopaedic team and placed on the emergency surgical theatre list. Due to a high volume of trauma patients admitted to the hospital, there were significant waiting times for access to theatre. The orthopaedic intern on the ward prescribed paracetamol and modified-release oxycodone 20mg twice daily, which was uptitrated to 30mg twice daily after three days. Later that week, he underwent operative fixation of the fracture. The anaesthetic team avoided regional anaesthesia due to the risk of compartment syndrome. His pain did not decrease in the expected manner postoperatively and this affected his engagement with physiotherapy. His modified-release oxycodone was uptitrated to 40mg twice daily. Due to substantial bed pressure that existed in the hospital, he was discharged on the third postoperative day with a script for analgesia and a follow-up appointment in the orthopaedic clinic in 6 weeks’ time. The discharging intern made sure he had sufficient analgesia to cover him for this period. When he presented to a busy orthopaedic clinic 6 weeks’ later, he remained on modified-release oxycodone. He requested that his script be refilled and this request was granted.
Opioid analgesics are highly effective in the management of acute severe pain. However, their use in a chronic setting is associated with an increased risk of opioid misuse, overdose and tolerance among other risks. A systematic review conducted by the Agency for Healthcare Research and Quality concluded that insufficient evidence existed for the long-term benefits of opioids in chronic pain.1 As higher doses are often required in order to maintain adequate analgesia, dose-related risks such opioidinduced respiratory depression, opioid-induced bowel dysfunction and dependence become more common. In addition, their use in the elderly comes with an increased risk of cognitive impairment and falls. Despite a lack of evidence for their benefit in chronic pain, their use has increased substantially in many developed countries, including in Ireland.2 Increased prescribing rates can lead to opioid-use disorder and opioid diversion, with many patients reporting not disposing of finished opioid prescriptions.
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