Reducing Opioid Use after Ankle Fracture Surgery

    Helping patients to better manage stress and improve coping strategies related to pain may minimize the need for opioids following ankle fracture surgery, according to research published in the Journal of the American Academy of Orthopaedic Surgeons.

    The US is facing an opioid epidemic, with millions of people dependent on or misusing prescription painkillers such as codeine, morphine, oxymorphone, tramadol, hydrocodone, and oxycodone.

    In 2015 alone, more than 15,000 people died from overdoses involving prescription opioids. A 2016 Washington Post/Kaiser Family Foundation survey found that 1 in 3 patients (34%) who took opioids for at least 2 months reported being addicted or dependent.

    “Opioid-centric pain relief strategies have led to safety concerns without adequately relieving pain,” said lead study author David Ring, MD, PhD, associate dean of comprehensive care and professor of surgery and perioperative care at the Dell Medical School at The University of Texas.

    “This is the latest in a series of studies demonstrating that pain relief after surgery or injury has more to do with calm and reassurance (self-efficacy) than with medication. Getting comfortable seems mostly about giving your body time to heal.”

    In the study, researchers sought to determine if opioid intake was associated with disability, satisfaction with surgery, and pain relief at the time of suture removal (1 to 2 weeks after surgery) and at the follow-up appointment 5 to 8 months later.

    The study involved 99 adult patients at suture removal and 59 patients at follow-up appointments. Disability, satisfaction, and pain were measured through questionnaires.

    Among the results:

    • No association was found between opioid intake and disability, satisfaction with the surgery, or satisfaction with pain management at the time of suture removal or at follow-up appointments.
    • Opioid use was independently associated with greater reported pain with activity and greater catastrophic thinking at suture removal and at follow-up appointments.
    • Greater disability also was associated with catastrophic thinking and a poor response to the surgery and pain.
    • Eight-four patients (83%) were using opioids at the time of suture removal. That number decreased to 14 out of 59 (24%) at the follow-up appointments.

    The study authors say the results “demonstrate the need for a comprehensive approach to pain relief after surgery, including optimization of the patient’s mindset and circumstances (with effective coping strategies being most important) in addition to the use of analgesics, elevation, ice, and other physical strategies.”

    Dr. Ring noted that “compassion, communication, and coordination” are key to minimizing opioid use following injury or surgery.

    “The preoperative discussion of pain relief is important,” he said. “Patients also should be screened for symptoms of depression, less-effective coping strategies, and/or the risk for misuse.”

    If necessary, surgeons should consult or partner with social workers, psychologists, or psychiatrists to assist at-risk patients.


    Finger A, Teunis T, Hageman MG, Ziady ER, Ring D, Heng M. Association between opioid intake and disability after surgical management of ankle fractures. J Am Acad Orthop Surg. 2017 Jul;25(7):519-526. doi: 10.5435/JAAOS-D-16-00505.