This year, a good friend underwent a revision hip arthroplasty for aseptic necrosis of the femoral head after a fracture fixation several years prior.  Being 80 years old and frail, she was offered rehab in an SNF postoperatively, but instead was confident her adult children and grandchildren could properly support her in the home setting.   Both this friend and her family assumed the oxycodone would take away most of the hip pain at rest and pain triggered by movement, but they were not aware of its common side effects or how they would know if the pain was adequately managed.  

This patient developed delirium, panic attacks, and partial ileus with abdominal bloating and exacerbation of GERD.  Her caregiver daughter was in tears when I arrived the next day and assessed the situation as a friend.  This patient had minor pain at rest, but had experienced terrible pain arising from her recliner, ambulating to the bathroom, toileting, and returning to bed or her recliner.  She did acknowledge that her pain was minor within minutes of reclining.  When I told her the terrible movement triggered pain was expected and that oxycodone could be causing many of her distressing post op symptoms, she agreed to substitute tramadol 50 mg at bedtime for nocturnal pain (a tolerated pre op pain med) and began Tylenol 650 mg q 6 hr.  Within 12 hours, the majority of the oxycodone side effects had resolved and her rest pain was minor.  She still had severe pain walking to her bathroom, but again this pain became minor within minutes of returning to bed or her recliner.  She subsequently rapidly recovered her function and within weeks returned to normal function apart from following hip dislocation precautions.  

If she had undergone rehabilitation in your skilled facility, how would your staff have approached her pain problem?  Would they have requested medicines for sedation, nausea, esophageal reflux, or stronger pain meds?  What would your targets be for pain management?  Would your targets differentiate triggered transient pain from persistent basal pain?  

My friend and her family didn’t understand how to optimally manage the postop pain and didn’t have a viable alternative pain management plan.  Because her movement-triggered pain quickly became tolerable with rest, the real issue was developing a pain plan for supporting sleep at night and reducing rehabilitation-related acute pain.  Tramadol worked will for both situations.  For rest pain, ice, Tylenol, visits with friends, music, and interesting online games and programming proved effective.  

I subsequently cared for SNF patients while providing vacation relief to colleagues.  I applied the same strategy for a patient with polypharmacy-associated frequent falls with a complicating hip fracture requiring ORIF.  Besides deprescribing, I applied the above approach and she did quite well.

I’m aware that postop analgesia may be approached with NSAIDS and other meds and opioids.  However, the principles are the same.  The interventions should have clear targets for acute and basal pain control and should include non-pharmacologic strategies that enhance function and quality of life.  We need to set realistic expectations and create pain plans with our patients and their families.  

When this happens, we are less likely to have complications that prolong their stay and reduce their satisfaction.  Your staff may also find their work more satisfying knowing their pain management plans are less chaotic and more effective.