Oxycodone hydrochloride vs acetaminophen and codeine after fracture surgery

Clinical pharmacists point to the limitations of the JAMA study which concluded that acetaminophen and codeine offer preferred postoperative pain management.

We read with great interest the recent publication in JAMA, “Effectiveness of Oxycodone Hydrochloride (Strong Opioid) vs Combination Acetaminophen and Codeine (Mild Opioid) for Subacute Pain After Fractures Managed Surgically” published by Jenkin et al. and would like to share our views on the limitations of this study.1

First, the dosage used in the codeine/acetaminophen arm (weak opioid arm) was lower than that generally used in the clinic. More appropriate dosing options include using equianalgesic doses of both opioids, as well as comparing both opioids in combination with acetaminophen (although it is not commercially available in a single dosage form in the country of origin). origin of the study). Although we realize that the terms “strong” and “weak” opioids are used by the World Health Organization in their cancer pain guidelines, we generally disagree with these terms as a means of categorizing opioids.

The use of the terms “strong”, “mild” or “weak” to describe opioids should be discouraged and more descriptive and specific terms such as “low potency” and “high potency”, “more effective” and “less potency “. effective.”2 By using an equianalgesic dosage, one could more closely dose codeine enough to match or exceed the dose of oxycodone used in this study.

Second, the investigators did not consider or comment on pharmacogenetics as an important factor that may affect the results of this study. Various pharmacogenetic abnormalities or drug interactions could dramatically alter how a patient responds to oxycodone alone compared to acetaminophen and codeine combined if cytochrome (CYP) P450 2D6 or CYP P450 3A4 is considered in the efficiency results.3.4

These concerns cannot be ignored when interpreting the use and generalizability of this study. Codeine, although less potent than oxycodone, has many negative characteristics that make it less than ideal as a method of reducing postoperative opioid exposure for fixation of long bone fractures.

Disclosures: Dr. Fudin points to the following potential conflicts: Abbott (speaker, non-speaker bureau), AcelRx Pharmaceuticals (speakers bureau, board), BioDelivery Sciences (collaborative publications, board, advisory boards), Collegium Pharmaceutical (studio recording education), Firstox (microserum testing for substances of abuse), GlaxoSmithKline (collaborative poster presentation; unpaid), Hisamitsu America (advisory board), Hikma Pharmaceuticals (advisory board), Lilly Pharmaceuticals (helping meeting registration), Scilex (collaborative, unpaid publications), Salix (speakers bureau, consulting, advisory boards), Torrent (conferences, non-speakers bureau).

Dr. Herndon reports receiving a consulting payment from the US Department of Justice and a grant from the Illinois Prescription Drug Monitoring Program.

Last update: January 27, 2022

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