NUR 602 Module 7 Milestone Two Example

Milestone Two: Scheduled Non-Opioids, a Three-Day Rescue and Naloxone for a 46-Year-Old With an Ankle Fracture

[Student Name]

Southern New Hampshire University

NUR 602: Advanced Pharmacology Across the Life Span

Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Scheduled Non-Opioids, a Three-Day Rescue and Naloxone for a 46-Year-Old With an Ankle Fracture

An acute injury in a middle-aged adult is one of the most common reasons an opioid is first prescribed, and the size of that first prescription shapes what follows. This milestone plans pain treatment for a man with a stable ankle fracture. It argues that scheduled non-opioid analgesics should carry the plan, that any opioid should be a small rescue supply with an end date, that his other drugs and conditions rule out some options entirely and that naloxone belongs in his hands because of his sleep apnea.

Patient and Injury

Marcus is 46, weighs 98 kg and supervises a warehouse shift. Yesterday he rolled his right ankle when he missed the last step at work. Radiographs show a nondisplaced fracture of the lateral malleolus below the level of the joint line, a stable pattern treated in a walking boot with weight bearing as tolerated. His pain is 7 out of 10 at rest and 9 with walking. He has obstructive sleep apnea and uses CPAP most nights, takes sertraline 100 mg daily for depression that has been in remission for two years and drinks two or three beers on weekends. His creatinine is 0.9 mg/dL, he has never had a peptic ulcer or a bleed and his blood pressure is 128/80. The state prescription monitoring program shows no controlled substance prescriptions in the past two years.

Goals

The goals are pain he rates at 4 or below at rest by day 3, the ability to walk in the boot and sleep through the night, return to modified work within a week and no opioid use after day 3. Success will be judged by these measures at follow-up rather than by the absence of pain, which is not a realistic aim after a fracture.

A Non-Opioid Base

The 2022 CDC guideline states that non-opioid therapies are at least as effective as opioids for many common types of acute pain, including sprains and minor fractures, and that clinicians should maximize them before considering an opioid (Dowell et al., 2022). The evidence is direct. In an emergency department trial of 411 adults with acute extremity pain, many with fractures, ibuprofen 400 mg with acetaminophen 1,000 mg lowered pain by 4.3 points at 2 hours, similar to oxycodone with acetaminophen at 4.4 points (Chang et al., 2017).

Marcus will take ibuprofen 600 mg every 6 hours with food and acetaminophen 1,000 mg every 8 hours, both on a schedule rather than as needed, for the first five days, then as needed. Because he drinks on weekends, his acetaminophen is capped at 3,000 mg a day, and he should avoid alcohol while taking it. Ice, elevation above the heart and the boot are part of the analgesic plan, not extras. A concern with NSAIDs after fracture is delayed healing. A meta-analysis found an association with nonunion in adults, but it was not significant when only higher-quality studies were analyzed (Wheatley et al., 2019), and a short course for a stable, low-risk fracture is reasonable.

A Rescue Opioid With an End Date

Some patients still need an opioid for the first few nights after a fracture. The size of the supply matters: in a large claims analysis, the likelihood of still using opioids a year later rose with each additional day in the first prescription, with sharp increases after the fifth day (Shah et al., 2017). The CDC guideline advises prescribing no more than the quantity needed for the expected duration of severe pain, which it notes is often three days or fewer (Dowell et al., 2022).

Marcus will receive oxycodone immediate release 5 mg, one tablet every 6 hours as needed for pain not controlled by the scheduled medicines, eight tablets total, no refills. Tramadol is avoided even though it is often seen as milder. It inhibits serotonin reuptake, and combined with sertraline it raises the risk of serotonin syndrome; it also lowers the seizure threshold and depends on CYP2D6 for activation, which sertraline can inhibit at higher doses. Codeine shares the CYP2D6 problem. Hydrocodone would be acceptable, but it offers no advantage over oxycodone.

Other adjuncts were considered and set aside. Gabapentin and pregabalin add sedation and, taken with an opioid, raise the risk of respiratory depression, a real concern with sleep apnea, and they have little evidence for acute fracture pain. Muscle relaxants such as cyclobenzaprine add drowsiness and anticholinergic effects without treating bone pain. Topical diclofenac gel is reasonable later, once swelling settles and he wants to reduce his oral ibuprofen. None of these would replace the scheduled base, and adding sedating drugs to an opioid in a man with sleep apnea would undo the safety the rest of the plan builds.

Naloxone and Safety

The CDC guideline recommends offering naloxone when a patient has factors that increase the risk of overdose, including sleep-disordered breathing, concurrent alcohol or sedative use and a history of depression (Dowell et al., 2022). Marcus has all three. He will receive a naloxone nasal spray, and his partner will be shown how to use it. He should wear his CPAP every night while taking oxycodone, never combine it with alcohol and not drive or operate warehouse equipment for at least six hours after a dose. Leftover tablets should be taken to a pharmacy take-back site or mixed with coffee grounds in a sealed bag and discarded.

Follow-Up

A phone check on day 3 will confirm pain scores, sleep, walking and whether any oxycodone remains. The orthopedic visit at two weeks will recheck alignment. If he still needs an opioid after day 3, the plan calls for reassessment of the fracture and the pain, not a refill by phone. Because he has a history of depression, his mood and sleep should be asked about, since injury and reduced activity can trigger a relapse.

Conclusion

For Marcus, scheduled ibuprofen and acetaminophen do most of the work, eight oxycodone tablets cover the worst nights, tramadol is excluded because of sertraline and naloxone is in the house because of his sleep apnea. The plan treats his pain now while lowering the chance that a twisted ankle becomes the start of long-term opioid use.

References

Chang, A. K., Bijur, P. E., Esses, D., Barnaby, D. P., & Baer, J. (2017). Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: A randomized clinical trial. JAMA, 318(17), 1661-1667. https://doi.org/10.1001/jama.2017.16190

Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain: United States, 2022. MMWR Recommendations and Reports, 71(3), 1-95. https://doi.org/10.15585/mmwr.rr7103a1

Shah, A., Hayes, C. J., & Martin, B. C. (2017). Characteristics of initial prescription episodes and likelihood of long-term opioid use: United States, 2006-2015. MMWR Morbidity and Mortality Weekly Report, 66(10), 265-269. https://doi.org/10.15585/mmwr.mm6610a1

Wheatley, B. M., Nappo, K. E., Christensen, D. L., Holman, A. M., Brooks, D. I., & Potter, B. K. (2019). Effect of NSAIDs on bone healing rates: A meta-analysis. Journal of the American Academy of Orthopaedic Surgeons, 27(7), e330-e336. https://doi.org/10.5435/JAAOS-D-17-00727