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...
| Main Authors: | , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
BMJ Publishing Group
2022-09-01
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| Series: | Trauma Surgery & Acute Care Open |
| Online Access: | https://tsaco.bmj.com/content/7/1/e000862.full |
| _version_ | 1797787161187057664 |
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| author | Gail T Tominaga Kathryn B Schaffer Jeffrey Smith Imad S Dandan Dunya Bayat Tala H Dandan Walter L Biffl Jiayan Wang Matthew R Castelo Sabina Schaffer Deb Snyder Chris Nalick |
| author_facet | Gail T Tominaga Kathryn B Schaffer Jeffrey Smith Imad S Dandan Dunya Bayat Tala H Dandan Walter L Biffl Jiayan Wang Matthew R Castelo Sabina Schaffer Deb Snyder Chris Nalick |
| author_sort | Gail T Tominaga |
| collection | DOAJ |
| 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. |
| first_indexed | 2024-03-13T01:19:00Z |
| format | Article |
| id | doaj.art-f76091010c784f0ba23101ae84d40b5b |
| institution | Directory Open Access Journal |
| issn | 2397-5776 |
| language | English |
| last_indexed | 2024-03-13T01:19:00Z |
| publishDate | 2022-09-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | Trauma Surgery & Acute Care Open |
| spelling | doaj.art-f76091010c784f0ba23101ae84d40b5b2023-07-05T07:00:07ZengBMJ Publishing GroupTrauma Surgery & Acute Care Open2397-57762022-09-017110.1136/tsaco-2021-000862Pain management on a trauma service: a crisis reveals opportunitiesGail T Tominaga0Kathryn B Schaffer1Jeffrey Smith2Imad S Dandan3Dunya Bayat4Tala H Dandan5Walter L Biffl6Jiayan Wang7Matthew R Castelo8Sabina Schaffer9Deb Snyder10Chris Nalick11Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USAOrthopedic Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USATrauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USAObjectives 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.https://tsaco.bmj.com/content/7/1/e000862.full |
| spellingShingle | Gail T Tominaga Kathryn B Schaffer Jeffrey Smith Imad S Dandan Dunya Bayat Tala H Dandan Walter L Biffl Jiayan Wang Matthew R Castelo Sabina Schaffer Deb Snyder Chris Nalick Pain management on a trauma service: a crisis reveals opportunities Trauma Surgery & Acute Care Open |
| 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 |
| url | https://tsaco.bmj.com/content/7/1/e000862.full |
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