Altered Pain Management Strategy Reduces Opioid Exposure in Trauma Patients, Study Finds

A pain management regimen consisting mostly of over-the-counter drugs reduced opioid exposure in trauma patients while achieving equal levels of pain control, according to a new study by physician-researchers at the Center for University of Texas at Houston Health Sciences (UTHealth).

The results of the study, which was conducted at the Red Duke Trauma Institute at Memorial Hermann-Texas Medical Center, were published today in the Journal of the American College of Surgeons.

“Research shows us that critically injured people with acute pain can be treated effectively with an opioid reduction strategy,” said John Harvin, MD, MS, associate professor in the department of surgery at McGovern Medical School at UTHealth and first corresponding author. of the study. “Narcotics are not the mainstay of acute pain treatment.” Harvin is also a trauma surgeon at the Red Duke Trauma Institute.

The randomized study evaluated two different combinations of various non-opioid analgesics in a total of 1,561 patients. The researchers set out to determine which combination could best reduce opioid exposure in hospital and after discharge for patients with acute trauma, such as pelvic and rib fractures.

A treatment strategy that minimizes opioids is known as the “original” because in 2013 Harvin’s team began giving it as a first-line treatment for pain and only prescribing opioids need. It contains more potent drugs including intravenous and oral acetaminophen, celecoxib, pregabalin, naproxen, gabapentin, tramadol (a narcotic) and, if needed, oxycodone. This strategy reduced opioid exposure by 31%, but tramadol did not reduce opioids and involved more expensive drugs that are not widely available.

In search of a more ideal strategy, the team created the MAST regimen, named after the study, called Multimodal Analgesic Strategies in Trauma. It included much more generic and affordable drugs: oral acetaminophen, naproxen, gabapentin, lidocaine patches and, if needed, opioids. The only medicine that requires a prescription is gabapentin.

Patients randomized to the MAST regimen received less opioid exposure per day – 34 milligram morphine equivalents (MMEs) compared to 48, and were more likely to be released without a prescription for opioids, including tramadol ( 38% against 33%). No clinically significant difference in pain scores was observed.

“Our first hypothesis was that the initial regimen would provide better control of acute pain because these drugs should theoretically have worked better. We figured that if we could control acute pain better initially, we could use less narcotic drugs overall, but the MAST regimen achieved equal levels of pain control and reduced overall opioid exposure, probably because he only understood opioids when necessary. Narcotics don’t need to be the first line of treatment for acute pain control, ”Harvin said.

The National Institute on Drug Abuse reports that 128 people die from opioid overdoses every day, based on 2018 data. The research is timely as opioid overdoses are on the rise, especially during the pandemic.

Data collected by the UTHealth School of Biomedical Informatics Center for Health System Analytics shows that in 2020 first responders in Houston received an average of 90 calls per month for opioid overdoses, peaking in June at 116 calls. . This is an increase from the 60 calls per month on average in 2018 and 80 in 2019.

“Last year we had a record number of opioid overdoses in America. This continues to be a serious problem that has been largely overshadowed by COVID-19. However, the COVID pandemic is acutely exacerbating the epidemic of opioids, ”Harvin said.

Many in the medical community say the problem stems in part from standards released by the Joint Commission in 2011, which require pain to be assessed as a fifth vital sign and encourage more aggressive pain treatments, including opioids. .

Since then, many healthcare professionals have relied on opioids to manage acute pain. Although surgical prescription drugs aren’t the only cause of opioid addiction, they are a big contributor, Harvin said.

“The best way to reduce a person’s risk of long-term use is to minimize their exposure during hospitalization and on discharge, and we now know that there are excellent non-opioid drugs available to treat.” effectively pain. We know that culture change will take time and effort, but we’re excited to learn how to make the most of drugs that minimize opioids to improve care and deliver a new model that can be adopted by any center. trauma. ”

“While much remains to be done to optimize and individualize pain treatment regimens for our diverse trauma population, this trial demonstrates the ability of Level 1 trauma centers to quickly and effectively learn from patients using a rigorous research methodology while simultaneously improving patient care, “said Lillian Kao, MD, MS, professor of surgery at McGovern Medical School and lead author of the study.” This type of learning and improvement continues is facilitated by a close relationship between the University Center (UTHealth), the Trauma Center (Red Duke Trauma Institute) and our research infrastructure (Center for Translational Injury Research). “Kao is also the Director of the Surgery Division of acute care at Memorial Hermann-TMC.

The MAST diet is now standard practice by UTHealth physicians at the Red Duke Trauma Institute. Researchers are working to adapt it to the treatment of acute burns.

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Funding for the trial was provided by UTHealth’s Center for Clinical Research and Evidence-Based Medicine at the Center for Translational Injury Research.

McGovern Medical School co-authors include Rondel Albarado, MD; Van Thi Thanh Truong, MS; Charles Green, PhD; Jon E. Tyson, MD, MPH; Claudia Pedroza, PhD; Ethan A. Taub, DO; David E. Meyer, MD, MS; Jessica A. Hudson, MD; Sasha D. Adams, MD; Laura J. Moore, MD; Michelle K. McNutt, MD; Charles E. Wade, PhD; and John B. Holcomb, MD, a former UTHealth faculty member.