Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.

Pain Management in Patients ≥65 years with a Fragility Fracture

Drug Therapy - see important notes below

1. Prescribe the following analgesia regularly:

  • Paracetamol oral 1g four times daily (or IV if unable to take orally). If weight ≤50kg, refer to paracetamol dosing information in Prescribing Notes for Acute Pain.
  • Morphine sulphate 10mg/5ml oral solution 4mg oral (or 2mg SC if unable to take orally) three times daily.

2. Prescribe breakthrough analgesia:

  • Morphine sulphate 10mg/5ml oral solution 4mg oral (or 2mg SC if unable to take orally) hourly as required.

3. Prescribe regular laxatives - lactulose, senna or macrogol (Laxido®). See Management of Constipation.

4. Prescribe anti-emetic only if required. See Management of Post-operative Nausea and Vomiting (PONV).

N.B. Use the HEPMA prescribing protocol under the protocol tab by searching for 'Fragility Fracture Analgesia'.

Review

Review prescription at 48 hours post-op or earlier if required:

  • If patient is comfortable (assess charted pain score and use of as required analgesia):
    • Stop regular morphine or reduce to twice daily
    • Continue as required morphine
  • If pain is inadequately controlled, discuss with the Pain Team.
  • Analgesia should be reviewed prior to discharge and morphine should not be prescribed routinely on discharge.

Important Notes

  • Seek senior advice from the Pain Team on analgesic choice if patient has known sensitivities or contraindications to the above medicines. 
  • Avoid commencing modified-release opioids, tramadol, non-steroidal anti- inflammatory drugs (NSAIDS) as new prescriptions (review need to continue if on at time of admission).
  • Avoid morphine if eGFR <10ml/min/1.73m2. Morphine metabolites may accumulate in Acute Kidney Injury (AKI) / Chronic Kidney Disease (CKD). Monitor for toxicity, e.g. respiratory depression/drowsiness.
  • Consider lower morphine dose if patient very frail or underweight (e.g. 2mg twice daily).
  • Certain patients may require increased doses of morphine.

 

Guideline reviewed August 2022
Page updated July 2023



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