From the Guidelines
For this elderly patient with compression fracture pain limiting mobility, I recommend adding a scheduled long-acting opioid such as morphine ER 15mg twice daily or oxycodone ER 10mg twice daily to provide consistent pain control, as supported by the American Pain Society and American College of Physicians clinical practice guideline 1, 2, 3, 4, 5, 6, 7, 8. The current regimen includes multiple as-needed medications but lacks a scheduled long-acting pain medication for baseline control. Additionally, consider adding a low-dose corticosteroid like dexamethasone 2-4mg daily for 5-7 days to reduce inflammation around the fracture sites, although the evidence for this is limited and systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica 7. A bone-specific approach with vertebroplasty or kyphoplasty should be considered if the patient is a candidate, as these procedures can provide significant pain relief for compression fractures. For non-pharmacological options, a properly fitted back brace may provide structural support and pain relief. Given the patient's advanced age and the focus on comfort care, optimizing the pain regimen should prioritize function and quality of life over concerns about long-term medication effects, as emphasized in the guidelines 1, 2, 3, 4, 5, 6, 7, 8. The addition of a scheduled long-acting opioid would provide more consistent pain control than the current as-needed approach, potentially improving mobility and facilitating discharge. The short-term steroid could help reduce inflammation that may be contributing to pain, while interventional approaches like vertebroplasty directly stabilize the fracture site, often providing immediate pain relief. Some key points to consider in managing this patient's pain include:
- The use of acetaminophen and NSAIDs for mild to moderate pain, with careful consideration of their potential risks and benefits 3, 4, 5, 6.
- The potential benefits and risks of opioid analgesics, including the risk of abuse, addiction, and other adverse events 1, 2, 3, 4, 5, 6, 7, 8.
- The importance of nonpharmacologic therapies, such as spinal manipulation, exercise therapy, and cognitive-behavioral therapy, in managing chronic low back pain 1, 2, 7, 8. It is essential to weigh the potential benefits and harms of each treatment option and to prioritize the patient's function and quality of life in making decisions about their care.
From the Research
Pain Management Optimization Options
The patient's current regimen includes acetaminophen, topical Lidocaine, topical gabapentin/ketoprofen compounded cream, fentanyl sublingual, and Hydromorphone liquid orally. To optimize pain management, consider the following options:
- Adjusting the current medication regimen, such as changing the dosage or frequency of administration, to better manage the patient's pain 9
- Adding or substituting other medications, such as bisphosphonates (e.g., zoledronic acid) or RANKL-inhibitors (e.g., denosumab), which have been shown to reduce skeletal-related events and pain in patients with bone metastases 10, 11
- Using a multidimensional tool to assess the patient's pain, including pain qualities, duration, impact on functional capabilities, and underlying cause, to inform the selection of a treatment regimen 12
- Considering the patient's age, sex, psychosocial features, and comorbid conditions when selecting a treatment regimen 12
- Implementing a "universal precautions" approach, including abuse risk assessment and abuse deterrence strategies, when prescribing opioids 12
Adjuvant Analgesics
Adjuvant analgesics, such as antiepileptic drugs, antidepressants, and local anesthetics, may be necessary to optimize pain control, especially in patients with neuropathic pain 13. Consider adding or substituting these medications to the patient's current regimen.
Opioid Management
Opioids are the mainstay of therapy for moderate to severe pain at the end of life 13. However, their use requires careful consideration of the risks and benefits, particularly in older adults. Consider the patient's individual needs and circumstances when selecting an opioid regimen, and monitor for potential adverse effects 9, 13.