Impact of a Multimodal Analgesia Protocol on Inpatient and Outpatient Opioid Use in Acute Trauma

Acute Pain Management in Traumatically Injured Patients With Outpatient Buprenorphine Therapy

INTRODUCTION

Acute pain management is challenging in trauma patients undergoing outpatient buprenorphine therapy at the time of injury due to the high binding affinity of this partial agonist. The purpose of this study was to evaluate acute pain management in admitted trauma patients with discontinued versus continued outpatient buprenorphine therapy.

MATERIALS AND METHODS

This retrospective study included adult trauma patients admitted to a level-1 trauma center between January 2017 and August 2020 who were receiving buprenorphine prior to admission. Groups were defined as buprenorphine discontinued (BD) or continued (BC) during hospitalization. The primary outcome compared median daily morphine milligram equivalents between groups. Secondary outcomes utilized patient-reported numeric rating scale (NRS) scores to compare incidences of no pain (NRS 0), mild (NRS 1-3), moderate (NRS 4-6), and severe (NRS 7-10) pain.

RESULTS

A total of 57 patients were included (BD 37 [64.9%] and BC 20 [35.1%]). The median (interquartile range) outpatient daily buprenorphine dose was similar between groups (8 [8-16] mg versus 16 [8-16], P = 0.25). Median daily morphine milligram equivalents was significantly higher during admission in the BD group (103.7 [80.7-166] versus 67 [30.8-97.4], P = 0.002). Incidence of no pain (7.1% versus 5.7%, P = 0.283), mild (5.5% versus 4.3%, P = 0.295), moderate (20.2%, 19.8%, P = 0.855), or severe (67.2% versus 70.2%, P = 0.185) pain was similar between BD and BC groups, respectively.

CONCLUSIONS

Continuation of outpatient buprenorphine therapy in acute trauma patients is associated with decreased daily opioid requirements and similar analgesic efficacy compared to patients with BD. Based on our findings, trauma patients receiving outpatient buprenorphine and not requiring ventilator support may benefit from buprenorphine continuation within 48 h of initial presentation.

Out of sight, out of mind? The impact on trauma patient opioid use when the medicine administration schedule is not displayed

INTRODUCTION

The impact of a visual pain medication schedule on opioid use among hospitalized trauma patients is unknown. We examined whether removal of this displayed schedule would decrease oral morphine equivalent (OME) use.

METHODS

This retrospective cohort study compared OME use in trauma patients in the inpatient setting before and after removing the patient-facing pain medication schedule that is typically displayed on the patient's white board for all trauma admissions.

RESULTS

707 patients were included. The control (n = 308, 43.6%) and intervention (n = 399, 56.4%) groups were similar in age (p = 0.06). There was no difference in total inpatient OME use between the control and intervention groups, median 50 (IQR: 22.5-118) vs 60 (IQR: 22.5-126), p = 0.79, respectively. No difference in total OME use was observed when patients were stratified by age, sex, race, ISS, and length of hospital stay.

CONCLUSION

Removing a visual display of the pain medication schedule did not decrease OME use in inpatient trauma patients.

Treating trauma more effectively: A review of psychosocial programming

IMPORTANCE

Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation.

OBSERVATIONS

Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented.

CONCLUSIONS AND RELEVANCE

The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.

The Declining Use of Opioids at a Level 1 Trauma Center

BACKGROUND

The epidemic of opioid-related overdose in the United States prompted a public health response that included implementation of opioid prescribing guidelines and restrictions. Such directives, however, were not applicable to hospitalized trauma patients. We hypothesized that although prescribing mandates did not apply to hospitalized trauma patients, inpatient opioid administration had nonetheless decreased over time.

METHODS

Opioid administrations for each patient admitted to a level I trauma center between January 1, 2016 and July 31, 2020 were converted into oral morphine milligram equivalents (MMEs) and summed at the patient level to obtain a total amount of MME administered for each hospitalization. MME was natural log transformed to achieve a normal distribution. General linear models were then used to determine the average patient MME administered by year. Patients who were pregnant or mechanically ventilated during their hospitalization were excluded.

RESULTS

Six thousand five hundred ninety-four patients were included in our analysis, of which 5037 (76.4%) were treated with opioids during their hospitalization (morphine 72.7%, oxycodone 9.6%, tramadol 10.2%, fentanyl 5.5%, and hydromorphone 2.1%). The percentage of patients administered an opioid decreased stepwise from 79.3% in 2016 to 71.4% in 2020 (P < .001). For patients administered opioids, a 28% decrease in average total MME from 2016 to 2020 (P < .001) was observed. When stratified by ISS (<9, 9-15, 16+), average total MME consistently trended downward over time.

CONCLUSION

Our trauma center realized a stepwise reduction in opioid administration in the absence of rules or restrictions surrounding in-hospital opioid prescribing.

Improving Opioid Prescribing Post-Discharge for Trauma Patients With Rib Fractures: Factors in Prevention of Prolonged Use and Dependency

BACKGROUND

Rib fracture (RF) pain management provides analgesia while reducing opioids. We postulated: (1) Prescriber factors affect opiate duration, and (2) lidocaine infusion curtails dependency.

MATERIALS AND METHODS

Retrospective study of RF patients undergoing multimodal analgesia at ACS-verified Level 1 Trauma Center April 2018-February 2020. Exclusions: age<18 y/o, GCS < 14, hospital length of stay (LOS) <3 d, <3 RF, ventilator support, injury-related mortality, disclosed/discoverable, acute/chronic opiate Rx within 90 days preadmission, substance abuse, patient inaccessible via Controlled Substance Monitoring Database (CSMD), and/or not using opioids in-/post-hospitalization. CSMD queried regarding opioid prescriptions filled by cohort. Cohort variable analysis performed on SPSS Version 27sf (Armonk, NY: IBM Corp).

RESULTS

153 patients included - 113 (74%) stopped opiates by 30 days post-discharge (NORx30), 40 (26%) continued beyond 30 days (Rx+). No significant differences in age, gender, ISS, number of RF, bilaterality, flail chest, and discharge disposition. Significant differences included hospital LOS (7.62 NORx30 vs. 10.22 Rx+, p = .02), number of prescribers (1.73 NORx30 vs. 2.98 Rx+, p < .01), average MME/day during initial 30 days post-discharge (36.7 ± 17 NORx30 vs. 45.4 ± 30.2 Rx+, p = .03), and number of pills (49 ± 38 NORx30 vs. 120 ± 85 Rx+, p < .01). Patients who received lidocaine infusion (LIDO+) had lower MME/day prescribed (32.24 ± 19.9, p = .03), were younger (61.2 vs. 65.6, p < .01), had more RFs (7.1 vs. 6.05, p = .03), and shorter LOS (7.71 vs 10.2, p = .01).

DISCUSSION

Prescriber attention to MME/day and number of pills dispensed affects opioid dependency. We recommend 35-40 MME/day with 50 pill/month limit prescribed by a single provider monitoring patient and CSMD. Early LI offers post-discharge opioid cessation advantage.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.