What strong alternative pain medication can be safely administered to a 73-year-old patient with a hip fracture who has already received morphine (opioid analgesic)?

From the Guidelines

For a 73-year-old patient with a hip fracture who has already received morphine, intravenous acetaminophen is a recommended alternative pain medication, administered every 6 hours as part of a multimodal analgesic approach. According to the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1, regular administration of intravenous acetaminophen is recommended as first-line treatment in managing acute trauma pain in the elderly. This approach is based on high-quality evidence and is considered a strong recommendation.

When considering alternative pain management options, it's essential to take into account the patient's medical history, current medications, and potential interactions. In this case, since the patient has already received morphine, it's crucial to monitor for signs of opioid overdose and to titrate any additional medications carefully.

Some key points to consider when administering intravenous acetaminophen to an elderly patient include:

• Starting with a regular dose of 650-1000mg every 6 hours, as recommended by the guidelines 1
• Monitoring liver function and adjusting the dose as needed to avoid hepatotoxicity
• Considering the addition of other non-opioid analgesics, such as NSAIDs, gabapentinoids, or lidocaine patches, as part of a multimodal pain management approach, if not contraindicated by the patient's medical condition 1
• Regularly assessing the patient's pain levels, respiratory rate, and mental status to ensure effective pain control and minimize side effects.

By following these guidelines and taking a multimodal approach to pain management, it's possible to provide effective pain relief for elderly patients with hip fractures while minimizing the risks associated with opioid use.

From the FDA Drug Label

NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain NSAID medicines should only be used: exactly as prescribed at the lowest dose possible for your treatment for the shortest time needed Get emergency help right away if you have any of the following symptoms: shortness of breath or trouble breathing chest pain weakness in one part or side of your body slurred speech swelling of the face or throat

Alternative pain medication: Naproxen, a Non-Steroidal Anti-Inflammatory Drug (NSAID), can be considered as a strong alternative pain medication for a 73-year-old patient with a hip fracture who has already received morphine.

• Key considerations:
  • Use exactly as prescribed
  • At the lowest dose possible
  • For the shortest time needed
  • Monitor for potential side effects, such as stomach pain, constipation, diarrhea, gas, heartburn, nausea, vomiting, dizziness, and others
  • Get emergency help right away if symptoms such as shortness of breath, chest pain, or swelling of the face or throat occur 2

From the Research

Alternative Pain Medication for Hip Fracture Patients

• A 73-year-old patient with a hip fracture who has already received morphine (opioid analgesic) may be safely administered intravenous acetaminophen as an alternative pain medication, as it has been shown to reduce the use of opioids after hip fracture 3.
• Non-steroidal anti-inflammatory drugs (NSAIDs) may also be considered for pain control during the peri-operative period of hip fracture surgery, as they have been found to be effective in some studies, but their safety data is conflicting with low levels of certainty 4.
• Acetaminophen, both intravenous and oral, has been proposed as a part of opioid-sparing multimodal analgesic pathways, but its effectiveness in reducing opioid utilization and opioid-related adverse effects is still being studied, with some studies showing conflicting results 5.

Considerations for Pain Management

• The use of opioid analgesics in elderly patients with hip fractures can lead to delirium, which is a common complication of geriatric hip fractures, with reported incidences from 16% to 70% 3.
• A multimodal approach to pain management, including the use of non-opioid therapies, regional anesthesia, and delirium prevention strategies, may be necessary to ensure the best outcomes for hip fracture patients 6.
• The choice of pain medication should be tailored to the individual patient's needs and medical history, taking into account factors such as comorbidities, cognitive impairment, and risk of adverse events 7.