A multimodal pain regimen (MMPR) designed to lessen opioid exposure and control acute pain linked to traumatic injury significantly lowered patients’ self-reported pain scores while also reducing the total amount of opioid medications given to trauma patients. The study was the first to evaluate an MMPR in a randomized controlled trial. The results were published online in the Journal of the American College of Surgeons’ Articles in Press section.
Less Dependence on Opioids
For decades now, the U.S. has been suffering from the consequences of the opioid epidemic. The current pandemic only made it worse, with people struggling to cope with isolation and addiction as limited visitations to doctors also limited the treatment for those who seek help from opioid addiction.
Now, people who suffered from substance abuse from the highly addictive medications are also looking to fight for their rights by filing an Opioid Epidemic lawsuit. Plaintiffs seek compensation for the adverse effects they suffered from opioids, such as withdrawal, attempts of self-destruction, and respiratory depression.
“Opioids should not be considered the pillar of treatment for acute pain after injury,” said the study’s lead author, John A. Harvin, MD, FACS, an associate professor for the department of surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth) and trauma surgeon at the Red Duke Trauma Institute at Memorial Hermann-Texas Medical Center.
Trauma patients are at a higher risk of developing an opioid drug disorder. These patients suffer from injuries that affect different parts of their body that would require multiple surgical procedures which can cause severe pain that any local or regional anesthesia cannot manage. Around 15 percent of trauma patients are at high risk of prolonged opioid use and are more likely to have a history of substance abuse as compared to the general population.
The increasing utilization of multimodal pain regimens aim to lessen opioid exposure, manage acute pain, and speed up the recovery process after surgery. In 2013, the trauma team at UTHealth and at the Red Duke Trauma Institute developed an MMPR for trauma, which reduced opioid exposure by 31 percent as well as patients’ reported pain score.
However, the teams used high-cost drugs for the study which were not largely available in the hospital, like intravenous acetaminophen and drugs at discharge which were not covered by health plans. The regimen for the 2013 study also involved the use of tramadol, then considered as a weak opioid, but is now considered as a narcotic-like drug.
A Modified Strategy
In 2018, the trauma team assessed the Multimodal Analgesic Strategies in Trauma (MAST) MMPR, which only gives opioids for breakthrough pain. MAST MMPR involves four classes of medications: nonsteroidal anti-inflammatory agents — ketorolac and naproxen, acetaminophen, gabapentin, and local lidocaine anesthetic patches.
The pragmatic study compared the effectiveness between the original MMPR and the MAST MMPR. It included all trauma patients who were admitted to the Red Duke Trauma Institute over the course of a year. Random patients in the emergency department were placed on either the original MMPR or the MAST MMPR.
Overall, 1,561 patients with different categories of injury were involved in the study. Almost half of patients in both groups suffer from rib fractures, 32 percent had long bone fractures, and 20 percent suffered from traumatic brain injuries.
Each day, patients in the MAST MMPR group received 14 fewer oral morphine milligram equivalents (MME): MAST MMPR patients received 34 MME per day as compared to the MMPR group’s 48 MME per day. This amount is equivalent to 10 milligram of oxycodone per day.
Both groups of patients had the same pain scores, which is 3.3.
The findings of the study have broad implications. “The MAST MMPR is a regimen that can be duplicated in any trauma center. However, first the culture of an institution needs to change. Implementation requires education, auditing feedback about responsible opioid prescribing, physician and nursing champions to lead efforts to change clinical practice, and managing the expectations of how to treat pain with other, non-opioid adjuncts,” Dr. Harvin explained.
The MAST MMPR is now a standard practice among physicians of the Red Duke Trauma Institute and UTHealth. The regimen is being utilized for the treatment of acute burn pain and is continuously being studied to give way for better management of acute pain and reduction of opioid intake in the first 72 hours of admission.
“Post-traumatic pain, even in the most severely injured patient, can be effectively treated in an opioid-minimizing manner,” Dr. Harvin said.
