Management of Acute Pain Due to Traumatic Injury in Patients with Chronic Pain and Pre-injury Opioid Use

2020 ◽  
Author(s):  
Danielle Fontaine ◽  
Melissa Red Hoffman
Keyword(s):  
Chronic Pain ◽  
Acute Pain ◽  
Traumatic Injury ◽  
Opioid Use

Predicting chronic pain after major traumatic injury

2019 ◽  
Vol 19 (3) ◽  
pp. 453-464 ◽  
Author(s):  
Elisabeth B. Powelson ◽  
Brianna Mills ◽  
William Henderson-Drager ◽  
Millie Boyd ◽  
Monica S. Vavilala ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Traumatic Injury ◽  
Opioid Use ◽  
Post Injury ◽  
Regional Analgesia ◽  
Final Model ◽  
Opioid Medications

Abstract Background and aims Chronic pain after traumatic injury and surgery is highly prevalent, and associated with substantial psychosocial co-morbidities and prolonged opioid use. It is currently unclear whether predicting chronic post-injury pain is possible. If so, it is unclear if predicting chronic post-injury pain requires a comprehensive set of variables or can be achieved only with data available from the electronic medical records. In this prospective study, we examined models to predict pain at the site of injury 3–6 months after hospital discharge among adult patients after major traumatic injury requiring surgery. Two models were developed: one with a comprehensive set of predictors and one based only on variables available in the electronic medical records. Methods We examined pre-injury and post-injury clinical variables, and clinical management of pain. Patients were interviewed to assess chronic pain, defined as the presence of pain at the site of injury. Prediction models were developed using forward stepwise regression, using follow-up surveys at 3–6 months. Potential predictors identified a priori were: age; sex; presence of pre-existing chronic pain; intensity of post-operative pain at 6 h; in-hospital opioid consumption; injury severity score (ISS); location of trauma, defined as body region; use of regional analgesia intra- and/or post-operatively; pre-trauma PROMIS Depression, Physical Function, and Anxiety scores; in-hospital Widespread Pain Index and Symptom Severity Score; and number of post-operative non-opioid medications. After the final model was developed, a reduced model, based only on variables available in the electronic medical record was run to understand the “value add” of variables taken from study-specific instruments. Results Of 173 patients who completed the baseline interview, 112 completed the follow-up within 3–6 months. The prevalence of chronic pain was 66%. Opioid use increased from 16% pre-injury to 28% at 3–6 months. The final model included six variables, from an initial set of 24 potential predictors. The apparent area under the ROC curve (AUROC) of 0.78 for predicting pain 3–6 months was optimism-corrected to 0.73. The reduced final model, using only data available from the electronic health records, included post-surgical pain score at 6 h, presence of a head injury, use of regional analgesia, and the number of post-operative non-opioid medications used for pain relief. This reduced model had an apparent AUROC of 0.76, optimism-corrected to 0.72. Conclusions Pain 3–6 months after trauma and surgery is highly prevalent and associated with an increase in opioid use. Chronic pain at the site of injury at 3–6 months after trauma and surgery may be predicted during hospitalization by using routinely collected clinical data. Implications If our model is validated in other populations, it would provide a tool that can be easily implemented by any provider with access to medical records. Patients at risk of developing chronic pain could be selected for studies on preventive strategies, thereby concentrating the interventions to patients who are most likely to transition to chronic pain.

scholarly journals Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Peggy Compton ◽  
Shoshana V. Aronowitz ◽  
Heather Klusaritz ◽  
Evan Anderson
Keyword(s):  
Chronic Pain ◽  
Substance Use ◽  
Acute Pain ◽  
Primary Diagnosis ◽  
Opioid Use ◽  
Treatment Interventions ◽  
Polysubstance Use ◽  
Discharge Rates ◽  
Discharge Outcomes ◽  
Icd 10

Abstract Background Patients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered. Methods We employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes. Results Sixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. Conclusions These findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.

scholarly journals A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPalTM): study protocol for a multisite randomized controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Jennifer A. Rabbitts ◽  
Chuan Zhou ◽  
Rocio de la Vega ◽  
Homer Aalfs ◽  
Caitlin B. Murray ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Randomized Controlled Trial ◽  
Spinal Fusion ◽  
Acute Pain ◽  
Controlled Trial ◽  
Opioid Use ◽  
Cognitive Behavioral Intervention ◽  
Postsurgical Pain ◽  
Randomized Controlled ◽  
Chronic Postsurgical Pain

Abstract Background Spinal fusion surgery is associated with severe acute postsurgical pain and high rates of chronic postsurgical pain in adolescents. Psychological distress, sleep disturbance, and low pain self-efficacy predict higher acute pain and likelihood of developing chronic postsurgical pain. Interventions targeting baseline psychosocial risk factors have potential to interrupt a negative trajectory of continued pain and poor health-related quality of life (HRQL) over time but have not yet been developed and evaluated. This randomized controlled trial will test effectiveness of a digital peri-operative cognitive-behavioral intervention (SurgeryPalTM) vs. education-control delivered to adolescents and their parents to improve acute and chronic pain and health outcomes in adolescents undergoing spine surgery. Methods Adolescents 12–18 years of age undergoing spinal fusion for idiopathic conditions, and their parent, will be recruited from pediatric centers across the USA, for a target complete sample of 400 dyads. Adolescents will be randomized into 4 study arms using a factorial design to SurgeryPalTM or education control during 2 phases of treatment: (1) pre-operative phase (one-month before surgery) and (2) post-operative phase (1 month after surgery). Acute pain severity and interference (primary acute outcomes) and opioid use will be assessed daily for 14 days following hospital discharge. Chronic pain severity and interference (primary acute outcomes), as well as HRQL, parent and adolescent distress, sleep quality, and opioid use/misuse (secondary outcomes), will be assessed at 3 months and 6 months post-surgery. Discussion Demonstration of effectiveness and understanding optimal timing of perioperative intervention will enable implementation of this scalable psychosocial intervention into perioperative care. Ultimately, the goal is to improve pain outcomes and reduce reliance on opioids in adolescents after spine surgery. Trial registration NCT04637802 ClinicalTrials.gov. Registered on November 20, 2020

scholarly journals Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

2020 ◽  
Vol 133 (2) ◽  
pp. 265-279 ◽  
Author(s):  
Michael Verret ◽  
François Lauzier ◽  
Ryan Zarychanski ◽  
Caroline Perron ◽  
Xavier Savard ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Postoperative Pain ◽  
Adverse Events ◽  
Pain Intensity ◽  
Acute Pain ◽  
Analgesic Effect ◽  
Mean Difference ◽  
Adult Patients ◽  
Opioid Use ◽  
Clinically Significant

Background Widely used for acute pain management, the clinical benefit from perioperative use of gabapentinoids is uncertain. The aim of this systematic review was to assess the analgesic effect and adverse events with the perioperative use of gabapentinoids in adult patients. Methods Randomized controlled trials studying the use of gabapentinoids in adult patients undergoing surgery were included. The primary outcome was the intensity of postoperative acute pain. Secondary outcomes included the intensity of postoperative subacute pain, incidence of postoperative chronic pain, cumulative opioid use, persistent opioid use, lengths of stay, and adverse events. The clinical significance of the summary estimates was assessed based on established thresholds for minimally important differences. Results In total, 281 trials (N = 24,682 participants) were included in this meta-analysis. Compared with controls, gabapentinoids were associated with a lower postoperative pain intensity (100-point scale) at 6 h (mean difference, −10; 95% CI, −12 to −9), 12 h (mean difference, −9; 95% CI, −10 to −7), 24 h (mean difference, −7; 95% CI, −8 to −6), and 48 h (mean difference, −3; 95% CI, −5 to −1). This effect was not clinically significant ranging below the minimally important difference (10 points out of 100) for each time point. These results were consistent regardless of the type of drug (gabapentin or pregabalin). No effect was observed on pain intensity at 72 h, subacute and chronic pain. The use of gabapentinoids was associated with a lower risk of postoperative nausea and vomiting but with more dizziness and visual disturbance. Conclusions No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

scholarly journals P026: Opioid use and dependence three months after an emergency department visit for acute pain

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S66-S66
Author(s):  
R. Daoust ◽  
J. Paquet ◽  
J. Morris ◽  
A. Cournoyer ◽  
E. Piette ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chronic Pain ◽  
Acute Pain ◽  
Opioid Dependence ◽  
Tertiary Care ◽  
Structured Interview ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Convenience Sample

Introduction: Most studies evaluating prescription opioid dependence or misuse are retrospective and are based on prescription filling rates from pharmaceutical databases. These studies cannot evaluate if opioids are really consumed nor differentiate if used for a new pain, chronic pain, or for misuse/dependence. The aim of this study was to assess the opioid consumption in emergency department (ED) patients three months after discharge with an opioid prescription. Methods: This prospective cohort study was conducted in the ED of a tertiary care centre with a convenience sample of patients aged 18 years and older, recruited 24/7, who consulted and were discharged for an acute pain condition ( 2 weeks). We excluded patients who: did not speak French or English, were using opioid medication prior to their ED visit, with an ED stay > 48 hours, or suffering from cancer or chronic pain. Three months post-ED visit, participants were contacted by phone for a structured interview on their past two-week opioid use, their reasons for consuming them, and also answered the Rapid Opioid Dependence Screen (RODS) questionnaire. Results: In the 524 participants interviewed at three months (mean age ± SD: 51±16 years, 47% women), 44 (8.4%) patients consumed opioids in the previous two weeks. Among those, 72% consumed opioids for their initial pain, 19% for a new unrelated pain, and 9% for another reason. In this entire cohort, only five patients (1%) tested positive to opioid dependence from the RODS test. The low dependence incidence could be affected by a social desirability bias. Conclusion: This study suggests that opioid use at 3-month, for patients initially treated for acute pain, is associated with opioid dependency in 1% or possible misuse in only 9%. Additional prospective studies using multiple methods to measure opioids consumption, misuse, and dependence are needed.

scholarly journals Common Biological Modulators of Acute Pain: An Overview Within the AAAPT Project (ACTTION-APS-AAPM Acute Pain Taxonomy)

Pain Medicine ◽  
2020 ◽  
Vol 21 (10) ◽  
pp. 2394-2400
Author(s):  
Michele Curatolo
Keyword(s):  
Chronic Pain ◽  
Acute Pain ◽  
Pain Sensitivity ◽  
Surgical Techniques ◽  
Well Being ◽  
Opioid Consumption ◽  
Screening Tools ◽  
Opioid Use ◽  
Acute Low Back Pain

Abstract Objective The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) project relies on the identification of modulators to improve characterization and classification of acute pain conditions. In the frame of the AAAPT effort, this paper presents an overview of common biological modulators of acute pain. Methods Nonsystematic overview. Results Females may experience more acute pain than males, but the clinical significance may be modest. Increasing age is associated with decreasing analgesic requirement and decreasing pain intensity after surgery and with higher risk of acute low back pain. Racial and ethnic minorities have worse pain, function, and perceived well-being. Patients with preexisting chronic pain and opioid use are at higher risk of severe acute pain and high opioid consumption. The OPRM1 gene A118G polymorphism is associated with pain severity and opioid consumption, with modest quantitative impact. Most studies have found positive associations between pain sensitivity and intensity of acute clinical pain. However, the strength of the association is unclear. Surgical techniques, approaches, and complications influence postoperative pain. Conclusions Sex, age, race, ethnicity, preexisting chronic pain and opioid use, surgical approaches, genetic factors, and pain sensitivity are biological modulators of acute pain. Large studies with multisite replication will quantify accurately the association between modulators and acute pain and establish the value of modulators for characterization and classification of acute pain conditions, as well as their ability to identify patients at risk of uncontrolled pain. The development and validation of quick, bed-side pain sensitivity tests would allow their implementation as clinical screening tools. Acute nonsurgical pain requires more investigation.

Retrospective analysis on the effect of spinal cord stimulation on opioid consumption

2020 ◽  
Author(s):  
Awinita Barpujari ◽  
Michael A Erdek
Keyword(s):  
Spinal Cord ◽  
Chronic Pain ◽  
Retrospective Analysis ◽  
Spinal Cord Stimulation ◽  
Alternative Therapy ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Number Of Patients ◽  
Chronic Pain Conditions ◽  
Post Trial

Aim: Spinal cord stimulation (SCS) is used to clinically manage and/or treat several chronic pain etiologies. A limited amount is known about the influence on patients' use of opioid pain medication. This retrospective analysis evaluated SCS effect on opioid consumption in patients presenting with chronic pain conditions. Materials & methods: Sixty-seven patients underwent a temporary trial device, permanent implant or both. Patients were divided for assessment based on the nature of their procedure(s). Primary outcome was change in morphine equivalent dose (MED), ascertained from preoperative and postoperative medication reports. Results: Postoperative MED was significantly lower in patients who received some form of neuromodulation therapy. Pretrial patients reported an average MED of 41.01 ± 10.23 mg per day while post-trial patients reported an average of 13.30 ± 5.34 mg per day (p < 0.001). Pre-implant patients reported an average MED of 39.14 ± 13.52 mg per day while post-implant patients reported an average MED of 20.23 ± 9.01 mg per day (p < 0.001). There were no significant differences between pre-trial and pre-implant MED, nor between post-trial and post-implant MED. Of the 42 study subjects who reported some amount of pre-intervention opioid use, 78.57% indicated a lower MED (n = 33; p < 0.001), 16.67% indicated no change (n = 7) and 4.76% (n = 2) indicated a higher MED, following intervention. Moreover, SCS therapy resulted in a 26.83% reduction (p < 0.001) in the number of patients with MED >50 mg per day. Conclusion: Spinal cord stimulation may reduce opioid use when implemented appropriately. Neuromodulation may represent alternative therapy for alleviating chronic pain which may avoid a number of deleterious side effects commonly associated with opioid consumption.

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