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Pain management on a trauma service: a crisis reveals opportunities

OBJECTIVES: The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty...

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Autores principales: Schaffer, Sabina, Bayat, Dunya, Biffl, Walter L, Smith, Jeffrey, Schaffer, Kathryn B, Dandan, Tala H, Wang, Jiayan, Snyder, Deb, Nalick, Chris, Dandan, Imad S, Tominaga, Gail T, Castelo, Matthew R
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8948384/
https://www.ncbi.nlm.nih.gov/pubmed/35402732
http://dx.doi.org/10.1136/tsaco-2021-000862
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author Schaffer, Sabina
Bayat, Dunya
Biffl, Walter L
Smith, Jeffrey
Schaffer, Kathryn B
Dandan, Tala H
Wang, Jiayan
Snyder, Deb
Nalick, Chris
Dandan, Imad S
Tominaga, Gail T
Castelo, Matthew R
author_facet Schaffer, Sabina
Bayat, Dunya
Biffl, Walter L
Smith, Jeffrey
Schaffer, Kathryn B
Dandan, Tala H
Wang, Jiayan
Snyder, Deb
Nalick, Chris
Dandan, Imad S
Tominaga, Gail T
Castelo, Matthew R
author_sort Schaffer, Sabina
collection PubMed
description OBJECTIVES: The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). METHODS: Retrospective analysis of pain management at a level II trauma center for January–November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. RESULTS: 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. CONCLUSIONS: Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. LEVEL OF EVIDENCE: IV.
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spelling pubmed-89483842022-04-08 Pain management on a trauma service: a crisis reveals opportunities Schaffer, Sabina Bayat, Dunya Biffl, Walter L Smith, Jeffrey Schaffer, Kathryn B Dandan, Tala H Wang, Jiayan Snyder, Deb Nalick, Chris Dandan, Imad S Tominaga, Gail T Castelo, Matthew R Trauma Surg Acute Care Open Original Research OBJECTIVES: The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). METHODS: Retrospective analysis of pain management at a level II trauma center for January–November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. RESULTS: 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. CONCLUSIONS: Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. LEVEL OF EVIDENCE: IV. BMJ Publishing Group 2022-03-24 /pmc/articles/PMC8948384/ /pubmed/35402732 http://dx.doi.org/10.1136/tsaco-2021-000862 Text en © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. https://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ (https://creativecommons.org/licenses/by-nc/4.0/) .
spellingShingle Original Research
Schaffer, Sabina
Bayat, Dunya
Biffl, Walter L
Smith, Jeffrey
Schaffer, Kathryn B
Dandan, Tala H
Wang, Jiayan
Snyder, Deb
Nalick, Chris
Dandan, Imad S
Tominaga, Gail T
Castelo, Matthew R
Pain management on a trauma service: a crisis reveals opportunities
title Pain management on a trauma service: a crisis reveals opportunities
title_full Pain management on a trauma service: a crisis reveals opportunities
title_fullStr Pain management on a trauma service: a crisis reveals opportunities
title_full_unstemmed Pain management on a trauma service: a crisis reveals opportunities
title_short Pain management on a trauma service: a crisis reveals opportunities
title_sort pain management on a trauma service: a crisis reveals opportunities
topic Original Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8948384/
https://www.ncbi.nlm.nih.gov/pubmed/35402732
http://dx.doi.org/10.1136/tsaco-2021-000862
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