For an adult with an impacted proximal humerus fracture, how many opioid pain medication refills are appropriate?

Opioid Refills for Impacted Proximal Humerus Fractures

For an adult with an impacted proximal humerus fracture, prescribe no opioid refills—the initial prescription should provide 3 days or less of immediate-release opioids, which is sufficient for most acute musculoskeletal injuries, and additional opioids should only be prescribed after re-evaluation if severe pain persists beyond this period. 1

Initial Opioid Prescription Strategy

• Prescribe immediate-release opioids for 3 days or less as the initial prescription, as the CDC guideline states that three days or less will often be sufficient for acute pain, and more than seven days will rarely be needed 1
• The lowest effective dose should be prescribed with no greater quantity than needed for the expected duration of severe pain 1
• Avoid prescribing additional opioids "just in case" pain continues longer than expected, as this practice contributes to excess opioid availability and potential diversion 1

Evidence Against Routine Opioid Use

• The American College of Physicians and American Academy of Family Physicians conditionally recommend against treating patients with acute musculoskeletal injuries with opioids, including tramadol, based on the balance of benefits and harms 1
• Research demonstrates that patients with proximal humerus fractures consume an average of only 9.1 opioid pills over 3.7 days when prescribed for nonoperative treatment, suggesting that initial prescriptions exceeding this amount result in unused medication 2
• Proximal humerus fractures are associated with higher opioid requirements compared to distal upper extremity injuries, but the mean consumption still remains under 10 pills total 3

Multimodal Analgesia as First-Line Treatment

• Topical NSAIDs with or without menthol gel should be used as first-line therapy (strong recommendation) to reduce pain, improve physical function, and enhance treatment satisfaction 1
• Oral NSAIDs or acetaminophen should be added as second-line agents to reduce or relieve pain 1
• Regional anesthesia techniques, such as interfascial plane blocks, provide effective analgesia for proximal humerus fractures and can reduce reliance on systemic opioids 4

Re-evaluation Protocol Instead of Refills

• Re-evaluate patients who experience severe pain continuing beyond 3 days to confirm or revise the initial diagnosis and adjust management accordingly, rather than automatically providing refills 1
• The World Journal of Emergency Surgery recommends multimodal analgesia with scheduled non-opioid analgesics (acetaminophen, NSAIDs) rather than escalating opioid therapy 1
• If opioids remain necessary after re-evaluation, prescribe only the additional quantity needed for the anticipated remaining duration of severe pain, not a full refill 1

Critical Pitfalls to Avoid

• Do not prescribe extended-release or long-acting opioid formulations (such as methadone, fentanyl patches, or extended-release oxycodone) for acute fracture pain, as these have longer half-lives and increased risk of respiratory depression 1
• Avoid the common practice of prescribing 30-day supplies or multiple refills upfront, as this significantly increases the risk of long-term opioid use—each additional day of early opioid exposure increases the likelihood of chronic use 1
• Do not use opioids as monotherapy; the Association of Anaesthetists warns against administering opioid analgesics as the sole adjunct due to greater risk of respiratory depression and postoperative confusion in this patient population 1

Special Considerations for Elderly Patients

• Reduce opioid dosing by 20-25% per decade after age 55, as older trauma patients require fewer opioids than younger patients with similar pain scores 1
• Peripheral nerve blocks are particularly effective in elderly patients with proximal humerus fractures, reducing opioid consumption and associated adverse events such as acute confusional state 1