Pain management in trauma patients affected by the opioid epidemic: A narrative review

Implementation of a Quality Improvement Learning Collaborative to Support Implementation of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain: Case Study from Nurse-Led Clinics

PURPOSE

The authors describe a case study of a quality improvement initiative to implement the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain2 ("2016 CDC Guideline") into nurse-led primary care practices in central Appalachia.

DESIGN

In this controlled pre-post quality improvement study, a policy change, an electronic health record form, and supporting education were implemented. Knowledge change and quality improvement metrics were measured before and after implementation.

DATA SOURCES

The data comprised pre- and post-knowledge survey and quality improvement metrics from the electronic health record.

RESULTS

After the implementation of the chronic pain intake form and supporting training and education, marked improvements in documentation and completion of the 2016 CDC Guideline and Tennessee Clinical Practice Guideline-concordant activities were observed, suggesting an increase in compliance with guidelines.

CONCLUSIONS

Quality improvement efforts that focus on opioid management best practices may be effective at enhancing 2016 CDC Guideline-concordant care in clinics, including nurse-led ones. Similar strategies could be trialed to ensure the 2022 CDC Clinical Practice Guideline recommendations for opioid and pain management are adopted effectively.

PRACTICE IMPLICATIONS

Interventions to improve opioid and pain management through quality improvement efforts require policy changes, clinician and patient education, and electronic record tools.

Community opioid dispensing after rib fracture injuries: CODI study

Background

Pain from rib fractures often requires inpatient management with opioid medication. The need for ongoing opioid prescriptions following hospital discharge is poorly understood. Harms associated with long-term opioid use are generally accepted. However, a deeper understanding of current prescribing patterns in this population at-risk is required.

Methods

A retrospective cohort of adult patients hospitalised in Queensland, Australia between 2014 and 2015 with rib fractures (ICD-10-AM: S22.3, S22.4, S22.5), was obtained from the Community Opioid Dispensing after Injury (CODI) study, which includes person-linked hospitalisation, mortality and community opioid dispensing data. Data were extracted 90-days prior to the index-hospitalisation and 720-days after discharge. Factors associated with long-duration (>90 days cumulatively) and increased end-dose were examined using multivariable logistic regressions, odds ratios (OR), and 95% confidence intervals (95% CI).

Results

In total, 4306 patients met the inclusion criteria, and 58.8% had opioids dispensed in the community within 30 days of hospital discharge. 23.6% had long-duration dispensing and 13.7% increased opioid end-doses. Pre-injury opioid use was most associated with long-duration (OR = 12.00, 95% CI 8.99-16.01) and increased end-dose (OR = 9.00, 95% CI 6.75-12.00). Females and older persons had higher odds of long-duration dispensing (Females OR = 1.75, 95% CI 1.38-2.22; Age 65+ OR = 1.86, 95% CI 1.32-2.61). Injury severity and presence of concurrent injuries were not statistically significantly associated with duration or dose (p > .05). Subsequent hospitalisations and death during the follow-up period had statistically significant associations with long-duration and increased end-dose (p < .001).

Conclusion

Opiate prescribing following rib fractures is prolonged in older, and female patients, beyond the traditionally reported recovery time frames requiring analgesia. Previous opioid use (without dependence) is associated with long-duration opioid use and increased end-dose in rib fracture patients. These results support the need for a collaborative health system approach and individualised strategies for high-risk patients with rib fractures to reduce long-term opiate use.

Level of Evidence

Level III, Prognostic/Epidemiological.

Multimodal analgesic strategies in polytraumatized patients

In recent years, the resuscitation of trauma patients has improved; however, pain related to trauma remains associated with systemic complications. In trauma patients, pain should be considered a vital sign, and its control is crucial for reducing complications, improving patient satisfaction, and enhancing the quality of life. The multimodal analgesia approach is the mainstay in pain control, and growing evidence in the literature supports a greater role of regional anesthesia in the management of trauma casualties. In this review, we offer the reader an updated general framework of the various approaches available for pain treatment in polytraumatized patients, with a focus on the opportunities presented by regional anesthesia. We will examine different types of locoregional anesthesia blocks and describe ultrasonographic execution techniques.

The heterogeneous wound microbiome varies with wound care pain, dressing type, and inflammatory gene expression

Wound dressing changes are essential procedures for wound management. However, ~50% of patients experience severe pain during these procedures despite the availability of analgesic medications, indicating a need for novel therapeutics that address underlying causes of pain. Along with other clinical factors, wound pathogens and inflammatory immune responses have previously been implicated in wound pain. To test whether these factors could contribute to severe pain during wound dressing changes, we conducted an exploratory, cross-sectional analysis of patient-reported pain, inflammatory immune responses, and wound microbiome composition in 445 wounds at the time of a study dressing change. We profiled the bacterial composition of 406 wounds using 16S ribosomal RNA amplicon sequencing and quantified gene expression of 13 inflammatory markers in wound fluid using quantitative real-time polymerase chain reaction (qPCR). Neither inflammatory gene expression nor clinically observed inflammation were associated with severe pain, but Corynebacterium and Streptococcus were of lower relative abundance in wounds of patients reporting severe pain than those reporting little or no pain. Wound microbiome composition differed by wound location, and correlated with six of the inflammatory markers, including complement receptor C5AR1, pro-inflammatory cytokine interleukin (IL)1β, chemokine IL-8, matrix metalloproteinase MMP2, and the antimicrobial peptide encoding cathelicidin antimicrobial peptide. Interestingly, we found a relationship between the wound microbiome and vacuum-assisted wound closure (VAC). These findings identify preliminary, associative relationships between wound microbiota and host factors which motivate future investigation into the directional relationships between wound care pain, wound closure technologies, and the wound microbiome.

Nonsteroidal anti-inflammatory drugs for analgesia in intensive care units: a survey of Canadian critical care physicians

PURPOSE

Opioids remain the mainstay of analgesia for critically ill patients, but its exposure is associated with negative effects including persistent use after discharge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be an effective alternative to opioids with fewer adverse effects. We aimed to describe beliefs and attitudes towards the use of NSAIDs in adult intensive care units (ICUs).

METHODS

Our survey of Canadian ICU physicians was conducted using a web-based platform and distributed through the Canadian Critical Care Society (CCCS) email distribution list. We used previously described survey development methodology including question generation and reduction, pretesting, and clinical sensibility and pilot testing.

RESULTS

We received 115 completed surveys from 321 CCCS members (36%). Nonsteroidal anti-inflammatory drugs use was most described as "rarely" (59 respondents, 51%) with the primary concern being adverse events (acute kidney injury [108 respondents, 94%] and gastrointestinal bleeding [92 respondents, 80%]). The primary preferred analgesic was acetaminophen (75 respondents, 65%) followed by opioids (40 respondents, 35%). Most respondents (91 respondents, 80%) would be willing to participate in a randomized controlled trial examining NSAID use in critical care.

CONCLUSIONS

In our survey, Canadian critical care physicians did not mention commonly using NSAIDs primarily because of concerns about adverse events. Nevertheless, respondents were interested in further studying ketorolac, a commonly used NSAID outside of the ICU, in critically ill patients.

Opioid Administration in the Trauma Bay for Minor Injuries Does Not Improve Disposition

OBJECTIVES

Opioid usage in the trauma bay is a common practice for pain management. We evaluated the administration of opioids to patients with minimal injury to determine disposition and factors for opioid administration.

METHODS

A retrospective study at a single institution was conducted utilizing records of trauma activations with an ISS of 3 or less between 1/1/2022 and 10/29/2022. Patients who are incarcerated, pregnant, or received an opioid prior to arrival were excluded. Categorical variables were analyzed using chi-square tests, and continuous variables were analyzed using t-tests.

RESULTS

557 patients met inclusion criteria. One in five patients were administered an opioid (22%). The majority of patients who received opioids were between the ages of 25 and 44 (OR 1.218 [.693, 2.141]), black (OR 3.077 [2.066, 4.584]), and had Medicaid insurance (OR 1.390 [.883, 2.187]). Patients who received an opioid reported a higher pain level (8 [6, 9] v 5 [2, 8], P = .0001), despite no difference in ISS. No significant difference was found in patient dispositions (P = .1759). When fentanyl was administered, doses greater than 50 mcg were administered to highest activation level trauma patients (40% v 10% P = .0001).

CONCLUSION

Opioid administration for patients with minor injuries does not improve patient disposition. The majority of patients with minor injuries being treated with opioids are young, black, and Medicaid patients. This research suggests consideration for establishing a non-opioid analgesic medication as first-line pain management for patients without evidence of significant injury on initial evaluation.

Establishing Geriatric Opiate Use Patterns in Trauma

Introduction: There is evidence that providers often overprescribe opiates in the postoperative period. Despite an ever-growing geriatric population, there is little research detailing current opiate usage in older patients after trauma. This population presents a unique set of challenges for pain management and prescription drug dependence due to sensitivity, a narrow therapeutic window, and high rates of pre-existing polypharmacy.Objective: Assess the use of narcotics in geriatric trauma patients with various injury patterns to establish a reference point for future intervention for reduction in narcotic dependence.Methods: We created a database of trauma patients' age ≥65 years admitted to a single level 1 trauma center in the Southeastern United States during the 2019 calendar year. Information gathered included patient factors, injury patterns, operative intervention, pain medications prescribed during hospitalization and at discharge, total and average daily morphine milligram equivalents (MME) inpatient and outpatient, and requests/prescriptions for narcotics at follow-up.Results: In 2019, there were 475 patients aged ≥65 admitted to our level 1 trauma center for acute traumatic injuries. 219 of those patients required operative intervention. Average total inpatient MME for this cohort was 169.0 with average daily MME of 22.89. The average total prescribed MME upon discharge was 79.27. There were 29 patients documented to request narcotic prescription refill at time of clinic follow-up, 27 of whom were prescribed a narcotic medication at follow-up.Conclusion: This dataset establishes a reference point for opiate use in geriatric trauma patients to facilitate further research for mitigation of risk in this population.

Buprenorphine Induction in Trauma Patients With Opioid Use Disorder - A Single Center Experience?

INTRODUCTION

Buprenorphine is a Food and Drug Administration-approved therapy for opioid use disorder, with proven efficacy in treatment retention and reduction in opioid use and mortality. Low-dose buprenorphine initiation or microinduction is a novel means of initiation that may allow for an easier transition in patients. Trauma patients have high rates of opioid use disorder and patient directed discharges (PDD). We hypothesized that patients initiated on a buprenorphine microinduction program would have increased protocol completion and fewer PDD compared with patients initiated historically on a traditional induction.

METHODS

Our retrospective cohort study compared buprenorphine microinduction and traditional induction in trauma patients at an urban level one trauma center between December 2020 and June 2022. Patients aged 18-89 y with traumatic injuries who received buprenorphine were included. Our primary outcome was in-hospital protocol completion, defined as reaching 16 mg of buprenorphine within 24 h or a documented stable dose. Statistical analysis was performed using chi-square for categorical variables and two sample t-tests for continuous variables.

RESULTS

Ninety-eight patients were included, with 46 initiating with microinduction and 52 initiating with traditional induction. There was no difference in protocol completion, (P = 0.29) and 83% of subjects who started an induction protocol completed it. Those who completed a protocol were more likely to be discharged home (P = 0.0002), had less PDD (P = 0.001), and had an increased likelihood of attending outpatient addiction clinic follow-up (P = 0.038).

CONCLUSIONS

Regardless of the protocol type, buprenorphine induction can be implemented in trauma patients with high protocol completion rates. In our population, those who complete a protocol had a higher likelihood of discharge home and postdischarge follow-up in addiction medicine clinic.

Substance-Use Disorders in Critically Ill Patients: A Narrative Review

Substance-use disorders (SUDs) represent a major public health concern. The increased prevalence of SUDs within the general population has led to more patients with SUD being admitted to intensive care units (ICUs) for an SUD-related condition or with SUD as a relevant comorbidity. Multiprofessional providers of critical care should be familiar with these disorders and their impact on critical illness. Management of critically ill patients with SUDs is complicated by both acute exposures leading to intoxication, the associated withdrawal syndrome(s), and the physiologic changes associated with chronic use that can cause, predispose patients to, and worsen the severity of other medical conditions. This article reviews the epidemiology of substance use in critically ill patients, discusses the identification and treatment of common intoxication and withdrawal syndromes, and provides evidence-based recommendations for the management of patients exposed to chronic use.

Effect of Alternatives to Opiates Program on Discharge Opioid Prescribing in Trauma Patients

Background: Opioid overdose deaths have increased over the last two decades, despite efforts to reduce prescribing. This study aimed to determine if a hospital-wide Alternatives to Opiates (ALTOSM) program reduced opioid prescribing in hospital and upon discharge after trauma. Objectives: The primary outcome was incidence of opioid prescribing at hospital discharge Pre- and Post-ALTO. Secondary outcomes were the percent of patients with in-hospital opioid, non-opioid and multimodal analgesia, and hospital and intensive care unit (ICU) length of stay (LOS). Methods: This is a single-center, retrospective analysis of patients >/ = 18 years old admitted for >24 hours with the primary diagnosis of traumatic injury between August 2018 - October 2019. Patients with alcohol or polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. Results: A total of 703 patients were included, 471 in Pre-ALTO and 232 in Post-ALTO groups. The mean age was 59 ± 22 years and most were male (58.7%). Mean initial Injury Severity Score (ISS) was 9.1 ± 7.7. Opioid prescribing at hospital discharge occurred more in the Post-ALTO group (132/332, 39.4% vs 90/203, 43.8%; P = .1237). Most patients were prescribed in-hospital opioid (332/471, 70.4% vs 203/232, 87.5%, P < .0001) and non-opioid (441/471, 93.6% vs 229/232, 98.7%; P = .0027) analgesics, or multimodal analgesia (397/471, 84.3% vs 203/232, 87.5%; P = .2591). Median hospital and ICU LOS were also similar between groups [5 (3-9) vs 4(3-7), P = .3427] and ICU [2(0-4) vs 3(2-5), P = .3461]. Conclusion: Opioids remain mainstay for trauma-related pain treatment. ALTOSM was not associated with less in-hospital or discharge opioid prescribing.

Opioid and non-opioid analgesic regimens after fracture and risk of serious opioid-related events

Background

Non-opioid analgesics are prescribed in combination with opioids among patients with long bone fracture to reduce opioid prescribing needs, yet evidence is limited on whether they reduce the risk of serious opioid-related events (SOREs). We compared the risk of SOREs among hospitalized patients with long bone fracture discharged with filled opioid prescriptions, with and without non-opioid analgesics.

Design

We identified a retrospective cohort of analgesic-naïve adult patients with a long bone fracture hospitalization using the Merative MarketScan Commercial Database (2013-2020). The exposure was opioid and non-opioid analgesic (gabapentinoids, muscle relaxants, non-steroidal anti-inflammatory drugs, acetaminophen) prescriptions filled in the 3 days before through 42 days after discharge. The outcome was the development of new persistent opioid use or opioid use disorder during follow-up (day 43 through day 408 after discharge). We used Cox proportional hazards regression with inverse probability of treatment weighting with overlap trimming to compare outcomes among those that filled an opioid and a non-opioid analgesic to those that filled only an opioid analgesic. In secondary analyses, we used separate models to compare those that filled a prescription for each specific non-opioid analgesic type with opioids to those that filled only opioids.

Results

Of 29 489 patients, most filled an opioid prescription alone (58.4%) or an opioid and non-opioid (22.0%). In the weighted proportional hazards regression model accounting for relevant covariates and total MME, filling both a non-opioid analgesic and an opioid analgesic was associated with 1.63 times increased risk of SOREs compared with filling an opioid analgesic only (95% CI 1.41 to 1.89). Filling a gabapentin prescription in combination with an opioid was associated with an increased risk of SOREs compared with those that filled an opioid only (adjusted HR: 1.84 (95% CI1.48 to 2.27)).

Conclusions

Filling a non-opioid analgesic in combination with an opioid was associated with an increased risk of SOREs after long bone fracture.

Level of evidence

Level III, prognostic/epidemiological.

Study type

Retrospective cohort study.

Incidence of acute compartment syndrome with routine use of regional anesthesia for patients with long bone fractures: a large single-center retrospective review from a level I trauma tertiary academic institution

INTRODUCTION

Traditionally, using peripheral nerve blocks (PNBs) in patients with long bone fractures has been limited due to concerns that it may interfere with the timely diagnosis of acute compartment syndrome (ACS). However, our large academic institution and level I trauma center have been using regional anesthesia routinely for pain management of patients with long bone fractures for more than a decade, with strict adherence to a comprehensive management protocol. The aim of this retrospective review is to present our experience with this practice.

METHODS

Following Institutional Review Board approval, we performed a retrospective chart review of patients with long bone fractures and ACS over a 10-year period (2008-2018).

RESULTS

26 537 patients were included in the review. Approximately 20% of these patients required surgery, and 91.5% of surgically treated patients received regional anesthesia. The incidence of ACS in our cohort was 0.1% or 1.017 per 1000 patients with long bone fractures.

CONCLUSION

Current recommendations on using PNBs in patients at risk for ACS have been mainly based on expert opinion and dated case reports. Due to the nature of the condition, prospective data are lacking. Our large observational dataset evaluated the risk of missing or delaying ACS diagnosis when PNBs were offered for trauma patients and demonstrated a relatively low incidence of ACS despite the routine use of PNBs under strictly protocolized conditions when patients were managed by a dedicated multidisciplinary care team.

Audio Distraction for Traction Pin Insertion: A Prospective Randomized Controlled Study

BACKGROUND

Insertion of a skeletal traction pin in the distal femur or proximal tibia can be a painful and unpleasant experience for patients with a lower-extremity fracture. The purpose of this study was to determine whether providing patients with audio distraction (AD) during traction pin insertion can help to improve the patient-reported and the physician-reported experience and decrease pain and/or anxiety during the procedure.

METHODS

A prospective randomized controlled trial was conducted at 2 level-I trauma centers. Patients ≥18 years of age who were conscious and oriented and had a medical need for skeletal traction were included. Patients were randomized to receive AD or not receive AD during the procedure. All other procedure protocols were standardized and were the same for both groups. Surveys were completed by the patient and the physician immediately following the procedure. Patients rated their overall experience, pain, and anxiety during the procedure, and physicians rated the difficulty of the procedure, both on a 1-to-10 Likert scale.

RESULTS

A total of 54 patients met the inclusion criteria. Twenty-eight received AD and 26 did not. Femoral fractures were the most common injury (33 of 55, 60.0%). Baseline demographic characteristics did not differ between the 2 groups. The overall patient-reported procedure experience was similar between the AD and no-AD groups (3.9 ± 2.9 [95% confidence interval (CI), 3.1 to 4.7] versus 3.5 ± 2.2 [95% CI, 2.9 to 4.1], respectively; p = 0.55), as was pain (5.3 ± 3.2 [95% CI, 4.4 to 6.2] versus 6.1 ± 2.4 [95% CI, 5.4 to 6.8]; p = 0.28). However, anxiety levels were lower in the AD group (4.8 ± 3.3 [95% CI, 3.9 to 5.7] versus 7.1 ± 2.8 [95% CI, 6.3 to 7.9]; p = 0.007). Physician-reported procedure difficulty was similar between the groups (2.6 ± 2.0 [95% CI, 2.1 to 3.1] versus 2.8 ± 1.7 [95% CI, 2.3 to 3.3]; p = 0.69).

CONCLUSIONS

AD is a practical, low-cost intervention that may reduce patient anxiety during lower-extremity skeletal traction pin insertion.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Opioid utilization after orthopaedic trauma hospitalization among Medicaid-insured adults

Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010-2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07-1.18) and those between 31-50 years of age (OR = 1.15, 95% CI: 1.08-1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71-0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83-0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66-0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51-65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage.

Community Opioid Dispensing after Injury (CODI): Cohort characteristics and opioid dispensing patterns

BACKGROUND

Despite a focus of opioid-related research internationally, there is limited understanding of long-term opioid use in adults following injury. We analysed data from the 'Community Opioid Dispensing after Injury' data linkage study.

AIMS

This paper aims to describe the baseline characteristics of the injured cohort and report opioid dispensing patterns following injury-related hospitalisations.

METHODS

Retrospective cohort study of adults hospitalised after injury (ICD-10AM: S00-S99, T00-T75) in Queensland, Australia between 1 January 2014 and 31 December 2015, prior to implementation of opioid stewardship programs. Data were person-linked between hospitalisation, community opioid dispensing and mortality collections. Data were extracted for 90-days prior to the index hospital admission, to establish opiate naivety, to 720 days after discharge. Median daily oral morphine equivalents (i.e., dose) were averaged for each 30-day interval. Cumulative duration of dispensing and dose were compared by demographic and clinical characteristics, stratified by drug dependency status.

RESULTS

Of the 129,684 injured adults, 61.3 % had no opioids dispensed in the 2-year follow-up period. Adults having any opioids dispensed in the community (38.7 %) were more likely older, female, to have fracture injuries and injuries with a higher severity, compared to those with no opioids dispensed. Longer durations and higher doses of opioids were seen for those with pre-injury opioid use, more hospital readmissions and repeat surgeries, as well as those who died in the 2-year follow-up period. Median dispensing duration was 24-days with a median daily end dose of 13 oral morphine equivalents. If dispensing occurred prior to the injury, duration increased 10-fold and oral morphine equivalents doubled. Adults with a documented dependency prior to, or after, the injury had significantly longer durations of use and higher doses than the rest of the cohort receiving opioids. Approximately 7 % of the total cohort continued to be dispensed opioids at 2-years post injury.

CONCLUSION

This is a novel population-level profile of opioid dispensing patterns following injury-related hospitalisation, described for the time period prior to the implementation of opioid stewardship programs and regulatory changes in Queensland. Detailed understanding of this pre-implementation period is critical for evaluating the impact of these changes moving forward.

Intercostal cryonerve block versus elastomeric infusion pump for postoperative analgesia following surgical stabilization of traumatic rib fractures

OBJECTIVE

Patients with blunt thoracic trauma requiring surgical stabilization of rib fractures (SSRF) frequently experience severe pain. Further, a rising prevalence of opioid-tolerant patients sustain traumatic injuries. The optimal pain management adjunct for concurrent use with SSRF remains uncertain. This study compared outcomes in patients undergoing SSRF with concomitant cryonerve block (CryoNB) or ropivacaine 0.2% elastomeric infusion pump (EIP).

METHODS

A single-center retrospective comparative analysis was performed at a level II trauma center. A query of our institution's trauma registry of consecutive patients undergoing SSRF from October 2017 to November 2020 with either intercostal CryoNB or ropivacaine 0.2% EIP was conducted. Opioid consumption in oral morphine equivalents (OME), patient-reported pain scores by numerical rating scale, and pulmonary function measured by incentive spirometry effort (mL) were collected at baseline and on postoperative days 1-3. Results were analyzed using a linear-mixed-effects model. Length of stay (LOS), complications, and hospital charges were assessed as secondary outcomes.

RESULTS

Twenty-six patients meeting inclusion criteria were evaluated. Patient demographics, injury, and surgical variables were similar between groups. The estimated effect for patients treated with CryoNB (n = 14) compared to EIP (n = 12) demonstrated a 25% (estimated -1.37 OME, 95% CI, -2.411 to -0.335, p = 0.01) reduction in hospital opioid requirements, fewer discharge opioids (41.3 mg (37.5-45) versus 175 mg (150- 200), p = 0.03), 22% (estimated -1.506, 95% CI, -2.722 to -0.290, p = 0.02) reduction in pain scores, and shorter postoperative LOS (4 days (4-5) versus 6 days (5-9.5), p = 0.04). Pulmonary function (estimated -48.8 mL, 95% CI, -312.74 to 215.05, p = 0.71), total hospital costs (CryoNB: $90,224 ± 34,633; EIP: $131,498 ± 73,072, p = 0.07), and complications were no different between cohorts.

CONCLUSION

The addition of intercostal CryoNB as an adjunct to multimodal pain management in trauma patients undergoing surgical fixation of rib fractures may be of benefit. Based on our early data, this technique appears to be promising in reducing opioid requirements and providing an extended duration of pain control without increased costs or complications.

Standardizing Opioids Prescribed at Discharge in Trauma Surgery

INTRODUCTION

Excessive opioid use after sustaining trauma has contributed to the opioid epidemic. Standardizing the quantity of opioids prescribed at discharge can improve prescribing behavior. We hypothesized that adopting new electronic medical record order sets would be associated with decreased morphine milligram equivalents (MME) prescribed at discharge for trauma patients.

METHODS

This was a quasi-experimental study examining opioid prescribing practices at a Level 1 Trauma Center. All patients ages 18-89 admitted to the Trauma Service from January 2017 through March 2021 and hospitalized for at least 2 d were included. In November 2020, new trauma admission and discharge order sets were implemented with recommended discharge opioid quantity based on inpatient opioid usage the day prior to discharge multiplied by five. Postintervention prescribing practices were compared to historical controls. The primary outcome was MME at discharge.

RESULTS

Baseline characteristics between preintervention and postintervention cohorts were comparable. There was a significant reduction in median MME prescribed at discharge postintervention (112.5 versus 75.0, P < 0.0001). Median inpatient MME usage also significantly reduced postintervention (184.1 versus 160.5; P < 0.0001). There were trends toward increased ideal prescribing per order set recommendation and a reduction in overprescribing. Patients receiving the recommended opioid quantity at discharge had the lowest opioid refill prescription rate (under: 29.6%, ideal: 7.3%, over: 19.7%, P < 0.0001).

CONCLUSIONS

For trauma patients requiring inpatient opioid therapy, a pragmatic and individualized intervention was associated with a reduced quantity of discharge opioids without negative outcomes. Reduction in inpatient opioid use was also associated with standardizing prescribing practices of surgeons with electronic medical record order sets.

Pharmacologic Interventions to Prevent Delirium in Trauma Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

To compare the relative efficacy of pharmacologic interventions in the prevention of delirium in ICU trauma patients.

DATA SOURCES

We searched Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Registry of Clinical Trials from database inception until June 7, 2022. We included randomized controlled trials comparing pharmacologic interventions in critically ill trauma patients.

STUDY SELECTION

Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias.

DATA EXTRACTION

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for network analysis were followed. Random-effects models were fit using a Bayesian approach to network meta-analysis. Between-group comparisons were estimated using hazard ratios (HRs) for dichotomous outcomes and mean differences for continuous outcomes, each with 95% credible intervals. Treatment rankings were estimated for each outcome in the form of surface under the cumulative ranking curve values.

DATA SYNTHESIS

A total 3,541 citations were screened; six randomized clinical trials (n = 382 patients) were included. Compared with combined propofol-dexmedetomidine, there may be no difference in delirium prevalence with dexmedetomidine (HR 1.44, 95% CI 0.39-6.94), propofol (HR 2.38, 95% CI 0.68-11.36), nor haloperidol (HR 3.38, 95% CI 0.65-21.79); compared with dexmedetomidine alone, there may be no effect with propofol (HR 1.66, 95% CI 0.79-3.69) nor haloperidol (HR 2.30, 95% CI 0.88-6.61).

CONCLUSIONS

The results of this network meta-analysis suggest that there is no difference found between pharmacologic interventions on delirium occurrence, length of ICU stay, length of hospital stay, or mortality, in trauma ICU patients.

Opioid administration in the prehospital setting for patients sustaining traumatic injuries: An evaluation of national emergency medical services data

INTRODUCTION

Despite concerns about long-term dependence, opioids remain the mainstay of treatment for acute pain from traumatic injuries. Additionally, early pain management has been associated with improved long-term outcomes in injured patients. We sought to identify the patterns of prehospital pain management across the United States.

METHODS

We used 2019 national emergency medical services (EMS) data to identify the use of pain management for acutely injured patients. Opioid specific dosing was calculated in morphine milligram equivalents (MME). The effects of opioids as well as adverse events were identified through objective patient data and structured provider documentation.

RESULTS

We identified a total of 3,831,768 injured patients, 85% of whom were treated by an advanced life support (ALS) unit. There were 269,281 (7.0%) patients treated with opioids, including a small number of patients intubated by EMS (n = 1537; 0.6%). The median opioid dose was 10 MME [IQR 5-10] and fentanyl was the most commonly used opioid (88.2%). Patients treated with opioids had higher initial pain scores documented by EMS than those not receiving opioids (median: 9 vs 4, p<0.001), and had a median reduction in pain score of 3 points (IQR 1-5) based on the final prehospital pain score. Adverse events associated with opioid administration, including episodes of altered mental status (n = 453; 0.2%) and respiratory compromise (n = 252; 0.1%), were rare. For patients with severe pain (≥8/10), 27.3% of patients with major injuries (ISS ≥15) were treated with opioids, compared with 24.8% of those with moderate injuries (ISS 9-14), and 21.4% of those with minor (ISS 1-8) injuries (p<0.001).

CONCLUSION

The use of opioids in the prehospital setting significantly reduced pain among injured patients with few adverse events. Despite its efficacy and safety, the majority of patients with major injuries and severe pain do not receive opioid analgesia in the prehospital setting.

Long-Term Prescription Opioid Use After Injury in Washington State 2015-2018

BACKGROUND

Patients with injury may be at high risk of long-term opioid use due to the specific features of injury (e.g., injury severity), as well as patient, treatment, and provider characteristics that may influence their injury-related pain management.

OBJECTIVES

Inform prescribing practices and identify high-risk populations through studying chronic prescription opioid use in the trauma population.

METHODS

Using the Washington State All-Payer Claims Database (WA-APCD) data, we included adults aged 18-65 years with an incident injury from October 1, 2015-December 31, 2017. We compared patient, injury, treatment, and provider characteristics by whether or not the patients had long-term (≥ 90 days continuous prescription opioid use), or no opioid use after injury.

RESULTS

We identified 191,130 patients who met eligibility criteria and were included in our cohort; 5822 met criteria for long-term use. Most had minor injuries, with a median Injury Severity Score = 1, with no difference between groups. Almost all patients with long-term opioid use had filled an opioid prescription in the year prior to their injury (95.3%), vs. 31.3% in the no-use group (p < 0.001). Comorbidities associated with chronic pain, mental health, and substance use conditions were more common in the long-term than the no-use group.

CONCLUSION

Across this large cohort of multiple, mostly minor, injury types, long-term opioid use was relatively uncommon, but almost all patients with chronic use post injury had preinjury opioid use. Long-term opioid use after injury may be more closely tied to preinjury chronic pain and pain management than acute care pain management.

Applicability and effectiveness of ultrasound combined with nerve stimulator-guided lumbosacral plexus block in the supine versus lateral position during surgeries for lower limb fracture-a prospective randomized controlled trial

BACKGROUND

Patients with lower limb fracture often have acute pain and discomfort from changes in position, and such pain affects early postoperative recovery. This study aimed to compare the applicability and effectiveness of ultrasound combined with nerve stimulator-guided lumbosacral plexus block (LSPB) in the supine versus lateral position during lower limb fracture surgery.

METHODS

We included 126 patients who underwent elective internal fixation for lower limb fracture who were divided into the S group and the L group by the random number table method and underwent LSPB guided by ultrasound combined with a nerve stimulator in the supine and lateral positions, respectively. The primary outcome was the dose of sufentanil used in surgery. The secondary outcomes were the maximum VAS (visual analogue scale) pain score at position placing for LSPB, the time of position placing, the time for nerve block,the number of puncture attempts,the haemodynamic indicators, the VAS score at 1, 12, and 24 h following surgery, postoperative satisfactory degree to analgesia and adverse events related to nerve block.

RESULTS

There was no statistically significant difference in dose of sufentanil used between the two groups(P = 0.142). The maximum VAS pain score at position placing(P < 0.01), the time of position placement(P < 0.01), the time for lumbar plexus block and the time of puncture attempts were significantly lower in the S group than in the L group (P < 0.01). However, the time for sacral plexus block was higher in the S group than in the L group (P = 0.029). There was no significant difference in haemodynamic indicators,number of puncture attempts for the sacral plexus, postoperative VAS scores, postoperative satisfactory degree to analgesia or adverse events related to nerve block between the two groups (all P > 0.05).

CONCLUSIONS

Our study provides a more comfortable and better accepted anaesthetic regimen for patients undergoing lower limb fracture surgery. LSPB in the supine position is simple to apply and has definite anaesthetic effects. Additionally, it has a high level of postoperative analgesia and therefore should be widely applied.

TRIAL REGISTRATION

The trial was registered prior to patient enrolment at the Chinese Clinical Trail Registry (Date:11/03/2021 Number: ChiCTR2100044117 ).

Opioid Sparing Effect of Ketamine in Military Pre-Hospital Pain Management - A Retrospective Study

BACKGROUND

Opioids are the most commonly used analgesics in acute trauma, but are limited by slow onset and significant adverse effects. Ketamine is an effective and widely used analgesic. This study was aimed to evaluate the effectiveness and opioid-sparing effects of ketamine when utilized in pre-hospital military trauma setting.

METHODS

A retrospective analysis of a pre-hospital military trauma registry between 2014 - 2020. Inclusion criteria were age ≥ 16 years, ≥2 documented pain assessments, at least one indicating severe pain, and administration of opioids and/or low-dose ketamine. Joint hypothesis testing was used to compare casualties who received opioids only to those who received ketamine on outcomes of pain score reduction and opioid consumption.

RESULTS

Overall, 382 casualties were included. 91 (24%) received ketamine (21 as a single analgesic), with a mean dose of 29 mg (SD 11). Mean reduction in pain scores (on an 11-point scale) was not significantly different; 4.3-point (2.8) reduction in the ketamine group and 3.7-points (2.4) in the opioid-only group (p = 0.095). Casualties in the ketamine group received a median of 10 mg (IQR 3.5, 25) of morphine equivalents (ME) compared with a median of 20 ME (10, 20) in the opioid-only group. In a multivariable multinomial logistic regression, casualties in the ketamine group were significantly more likely to receive a low (1-10 ME) rather than a medium (11-20 ME) dose of opioids compared to the opioid-only group (OR 0.032, CI 0.14 - 0.75).

CONCLUSIONS

The use of ketamine in the pre-hospital military setting as part of a pain management protocol was associated with a low rather than medium dose of opioids in a multivariable analysis, while the mean reduction in pain scores was not significantly different between groups. Using ketamine as a first-line agent may further reduce opioid consumption with a similar analgesic effect.

LEVELS OF EVIDENCE

Level IV, therapeutic/care management.

Intravenous Lidocaine for the Management of Traumatic Rib Fractures: A Double-Blind Randomized Controlled Trial (INITIATE Program of Research)

BACKGROUND

Traumatic rib fractures (TRFs) are common with a 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and death. Evidence exists for intravenous (IV) lidocaine's effectiveness and safety in post-operative thoracic and abdominal surgery and we hypothesized it would be effective in patients with TRFs.

METHODS

We conducted a single-centre, double-blind, randomized control trial comparing IV lidocaine plus usual analgesics to placebo infusion plus usual analgesics for 72-96 hours. Participants were adult trauma patients diagnosed with two or more TRFs requiring hospital admission. The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). Secondary outcomes included patient satisfaction and opioid requirements (standardized total morphine equivalents (TME)). The study was powered to detect a 20% reduction in pain scores, which has been deemed clinically meaningful.

RESULTS

36 patients were enrolled and randomized to IV lidocaine or placebo. Comparison of the mean VAS pain scores demonstrated significant pain reduction with movement in the lidocaine group compared to placebo (7.05 ± 1.72 vs 8.22 ± 1.28, p = 0.042). Although pain scores at rest were reduced in the lidocaine group, this difference was not statistically significant (3.37 ± 2.00 vs 3.82 ± 1.97, p = 0.519). Patient satisfaction was higher in the lidocaine group than the placebo group, though this did not reach statistical significance (8.3 (IQR 7.0, 9.6) vs 6.3 (IQR 5.2, 7.1), p = 0.105). TMEs were lower in the lidocaine group than the placebo group, but this difference did not reach statistical significance (167 (IQR 60, 340) vs 290 (IQR 148, 390), p = 0.194).

CONCLUSIONS

These results demonstrate that lidocaine has a beneficial analgesic effect in patients with TRFs. Future work is needed to evaluate lidocaine's ability to reduce patient important consequences of inadequate analgesia.

LEVEL OF EVIDENCE

Level 2: RCT with significance and only 1 negative criterion (Missing >20% data).

Pain Management Considerations in Patients with Opioid Use Disorder Requiring Critical Care

The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit (ICU) clinician with guidance and treatment options, including non-opioid analgesia, for patients receiving medications for opioid use disorder (MOUD) and for patients actively misusing opioids. Verification and continuation of the patient's outpatient MOUD regimen, specifically buprenorphine and methadone formulations, assessment of pain and opioid withdrawal, and treatment of acute pain with non-opioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and to reduce the risk of unplanned discharge and other associated morbidity. This article is protected by copyright. All rights reserved.

Discharge from the trauma centre: exposure to opioids, unmet information needs and lack of follow up-a qualitative study among physical trauma survivors

Background

Physical trauma is associated with mortality, long-term pain and morbidity. Effective pain management is fundamental in trauma care and opioids are indispensable for treating acute pain; however, the use and misuse of prescribed opioids is an escalating problem. Despite this, few studies have been directed towards trauma patients in an early phase of rehabilitation with focusing on experiences and perspectives of health and recovery including pain and persistent use of prescribed opioids with abuse potential. To explore pre- and post-discharge trauma care experiences, including exposure to opioids, physical trauma survivors were recruited from a major trauma centre in Norway that provides the highest level of surgical trauma care.

Method

Qualitative exploratory study. Individual semi-structured interviews were conducted among 13 trauma patients with orthopedic injuries, known to be associated with severe pain, six weeks post-discharge. The interviews were recorded, transcribed verbatim, and thematically analyzed with an interdisciplinary approach.

Results

The overarching theme was that discharge from the trauma centre and the period that immediately followed were associated with feelings of insecurity. The three main themes that were identified as contributing to this was (a) unmet information needs about the injury, (b) exposure to opioids, and (c) lack of follow-up after discharge from the hospital. Participants experienced to be discharged with prescribed opioids, but without information about their addictive properties or tapering plans. This, and lack of attention to mental health and psychological impact of trauma, gave rise to unmet treatment needs of pain management and mental health problems during hospitalization and following discharge.

Conclusion

The findings from this study suggest that in addition to delivery of high-quality biomedical trauma care, health professionals should direct more attention to psychosocial health and safe pain management, including post-discharge opioid tapering and individually tailored follow-up plans for physical trauma survivors.

Impact of opioid use disorder on resource utilization and readmissions after operative trauma

BACKGROUND

Although patients with opioid use disorder have been shown to be more susceptible to traumatic injury, the impact of opioid use disorder after trauma-related admission remains poorly characterized. The present nationally representative study evaluated the association of opioid use disorder on clinical outcomes after traumatic injury warranting operative intervention.

METHODS

The 2010 to 2018 Nationwide Readmissions Database was used to identify adult trauma victims who underwent major operative procedures. Injury severity was quantified using International Classification of Diseases Trauma Mortality Prediction Model. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were developed to assess the association of opioid use disorder on in-hospital mortality, perioperative complications, resource utilization, and readmissions.

RESULTS

Of an estimated 5,089,003 hospitalizations, 54,097 (1.06%) had a diagnosis of opioid use disorder with increasing prevalence during the study period. Compared with others, opioid use disorder had a lower proportion of extremity injuries and falls but greater predicted mortality measured by Trauma Mortality Prediction Model. After adjustment, opioid use disorder was associated with decreased odds of in-hospital mortality (adjusted odds ratio: 0.61; 95% confidence interval, 0.53-0.70) but had greater likelihood of pneumonia, infectious complications, and acute kidney injury. Additionally, opioid use disorder was associated with longer hospitalization duration as well as greater index costs and risk of readmission within 30 days (adjusted odds ratio: 1.36; 95% confidence interval, 1.25-1.49).

CONCLUSION

Opioid use disorder in operative trauma has significantly increased in prevalence and is associated with decreased in-hospital index mortality but greater resource utilization and readmission.

Non-pharmacological interventions for acute pain management in adult trauma victims: a scoping review

OBJECTIVE

This scoping review aimed to map non-pharmacological interventions to reduce acute pain in adult trauma victims.

INTRODUCTION

Acute pain is a consequence of a pathological or traumatic event, and a result of invasive or non-invasive health care procedures. Acute trauma pain, as well as its treatment, is one of the least-studied areas of acute pain. Although non-pharmacological interventions are responsible for pain relief among a significant number of patients, only a small percentage of patients receive non-pharmacological interventions.

INCLUSION CRITERIA

This scoping review considered all studies conducted on adult victims of trauma, aged 18 years or over, in pre-hospital emergency care, emergency rooms, and trauma-center settings. Studies were considered if they focused on non-pharmacological interventions designed to reduce acute pain, and were implemented and evaluated by health professionals. Non-pharmacological interventions of any type, duration, frequency, and intensity were considered.

METHODS

A comprehensive search strategy across 11 bibliometric databases and gray literature sources was developed. Full texts of selected citations were assessed in detail for eligibility by two independent reviewers. No other relevant studies were identified by searching the references of the included articles. Data extraction was performed independently by two reviewers using an instrument previously developed, and those reviewers were later responsible for its validation. Findings were then extracted directly into tables that are accompanied by a narrative summary to show how they relate to the objectives of the review conducted.

RESULTS

This scoping review included nine studies: two retrospective cohort studies, five randomized controlled trials, one case report, and one literature review for five different countries. Non-pharmacological interventions identified and administered to trauma victims in pre-hospital settings, emergency services, and trauma centers were as follows: acupressure, auricular acupressure, auricular acupuncture, transcutaneous electrical nerve stimulation, repositioning, use of pressure relief devices, massage, heat therapy, music therapy, relaxation therapy, immobilization, ice therapy, compression, elevation, and bandage. Non-pharmacological interventions were mainly developed by nurses, physicians, and paramedics. They were, in most studies, poorly described in terms of their efficacy and were mostly reported in minor traumas, such as simple fractures or small wounds.

CONCLUSIONS

Currently, there is no consensus for the implementation of non-pharmacological interventions in the treatment of acute trauma pain. Their application is primarily used for minor traumas, and their potential for the treatment of major traumas is yet unknown. No studies on the use of non-pharmacological interventions aimed at reducing the impact of traumatic adverse environments were identified. Further investigation on the effects of these interventions should be encouraged so that robust decisions and recommendations can be made.

Optimizing Pain Control and Minimizing Opioid Use in Trauma Patients

Adverse effects of opioids and the ongoing crisis of opioid abuse have prompted providers to reduce prescribing opioids and increase use of multiple nonpharmacologic therapies, nonopioid analgesics, and co-analgesics for pain management in trauma patients. Nonopioid agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, central α2 agonists, and lidocaine, can be used as adjuncts or alternatives to opioids in the trauma population. Complementary therapies such as acupuncture, virtual reality, and mirror therapy are modalities that also may be helpful in reducing pain. Performing pain assessments is fundamental to identify pain and evaluate treatment effectiveness in the critically ill trauma patient. The efficacy, safety, and availability of opioid-sparing therapies and multimodal pain regimens are reviewed.

Effect of Pain Management Electronic Order Sets on Opioid Use in Adult Rib Fracture Patients

BACKGROUND

Inpatient pain management order sets are an important and necessary tool for standardizing and enhancing pain management for patients with traumatic injury. The purpose of this study was to assess the impact of revised inpatient pain management electronic order sets on opioid usage for patients with significant chest wall trauma.

METHODS

A retrospective pre-post study was conducted for adult patients with 3 or more rib fractures admitted to the hospital at a Level 1 trauma center. Two periods were compared: 1 year prior to the order set changes and the period immediately after the revisions were implemented. Differences between medians were assessed using Kruskal-Wallis test by ranks, and differences between nominal variables were assessed with χ test.

RESULTS

Twenty-five patients were analyzed for each period. There was no significant change between periods in the total amount of opioid received per day. There was a significant reduction in intravenous (IV) opioid use on the general inpatient floor (61% vs. 24%, p = .01), as well as in the percentage of patients who received IV opioid within 24 hr of discharge (40% vs. 4%, p = .002).

CONCLUSION

Revised inpatient pain management order sets did not reduce overall opioid usage in a population of patients with 3 or more rib fractures. However, significant improvements were noted in decreased IV opioid usage on the general inpatient floors and within 24 hr of patient discharge from the hospital.

The Impact of Nonsteroidal Anti-inflammatory Drugs on Older Adult Trauma Patients With Hip Fractures

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) use is frequently recommended for multimodal analgesia to reduce opioid use. We hypothesized that increased NSAID utilization will decrease opioid requirements without leading to significant complications in older adult trauma patients undergoing hip fracture repair.

METHODS

An observational cross-sectional cohort study of 190,057 adult trauma patients over a 6-y period (2008-2014) in the national Premier Healthcare Database was performed. Patients aged 65 or older undergoing femur repair and hip arthroplasty following fractures due to falls were analyzed. Primary outcome was opioid use, and secondary outcomes included transfusion requirements, length of stay (LOS), and organ system dysfunction. Continuous outcomes were analyzed using mixed-effect linear regression models to assess the effect of NSAIDs on the day of surgery. Fixed effects were included for patient and hospital characteristics, comorbidities, co-treatments, and surgery. Random intercepts for each hospital were included to control for clustering. Categorical outcomes were similarly analyzed using mixed-effect logistic regression models.

RESULTS

NSAIDs decreased opioids prescribed (12.01 versus 11.43 morphine milligram equivalents) (odds ratio [OR], -0.23; confidence interval [CI] = -0.41, -0.06) without overall increased bleeding (40.83% versus 43.18%; OR, 1.02; CI = 0.99, 1.05). NSAIDs were associated with reduced LOS (5.61 versus 5.96 d; CI = -0.24, -0.12), intensive care unit admissions (9.73% versus 10.59%; OR, 0.91; CI = 0.86, 0.96), and pulmonary complications (OR, 0.88; CI = 0.83, 0.93). Additionally, there was a 21% prescribing variability based solely on hospital.

CONCLUSIONS

NSAIDs were associated with decreased opioid requirements, hospital LOS, and intensive care unit admissions in older adult trauma patients without overall increase in bleeding. NSAIDs should be considered in multimodal pain regimens, moreover, given prescribing variability guidelines are needed.

LEVEL OF EVIDENCE

Level III, Prognostic.