Ketamine for Acute Pain After Trauma: KAPT Trial

Abstract BackgroundEvidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain.MethodsThis is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and six months.DiscussionThis trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes.Trial Registration:The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on 10/16/2019 and is available at https://clinicaltrials.gov/ct2/show/NCT04129086?term=ketamine+injury&draw=2&rank=6

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548 Use of ketamine infusion in post cesarean pain management in patients with opioid use disorder

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2020.12.569 ◽

2021 ◽

Vol 224 (2) ◽

pp. S346-S347

Author(s):

Katie Andrinas ◽

Wendy Craig ◽

Joseph R. Wax ◽

Johanna Cobb ◽

Elizabeth Snow ◽

...

Keyword(s):

Pain Management ◽

Opioid Use Disorder ◽

Opioid Use ◽

Ketamine Infusion

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102 A two-centre survey of caregiver perspectives on opioid use for children’s acute pain management

Paediatrics & Child Health ◽

10.1093/pch/pxz066.101 ◽

2019 ◽

Vol 24 (Supplement_2) ◽

pp. e39-e39

Author(s):

Esther Jun ◽

Samina Ali ◽

Naveen Poonai ◽

Maryna Yaskina ◽

Amy Drendel ◽

...

Keyword(s):

Pain Management ◽

Acute Pain ◽

Opioid Use ◽

Acute Pain Management

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Acute Pain Management for Patients on Medication-Assisted Treatment for Opioid-Use Disorder

Topics in Pain Management ◽

10.1097/01.tpm.0000525815.84692.62 ◽

2017 ◽

Vol 33 (3) ◽

pp. 1-10

Author(s):

Elizabeth A. Mayerson ◽

Thomas Julian

Keyword(s):

Pain Management ◽

Acute Pain ◽

Opioid Use Disorder ◽

Opioid Use ◽

Acute Pain Management ◽

Medication Assisted Treatment

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1555: EVALUATION OF ACUTE PAIN MANAGEMENT IN TRAUMA PATIENTS ON HOME BUPRENORPHINE

Critical Care Medicine ◽

10.1097/01.ccm.0000812544.38918.29 ◽

2021 ◽

Vol 50 (1) ◽

pp. 781-781

Author(s):

Justin Culshaw ◽

Carolyn Philpott ◽

Krissy Reinstatler ◽

Paige Bradshaw ◽

Marisa Brizzi ◽

...

Keyword(s):

Pain Management ◽

Acute Pain ◽

Trauma Patients ◽

Acute Pain Management

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Chronic use of tramadol after acute pain episode: cohort study

BMJ ◽

10.1136/bmj.l1849 ◽

2019 ◽

pp. l1849 ◽

Cited By ~ 27

Author(s):

Cornelius A Thiels ◽

Elizabeth B Habermann ◽

W Michael Hooten ◽

Molly M Jeffery

Keyword(s):

Acute Pain ◽

Elective Surgery ◽

Risk Difference ◽

Administrative Claims ◽

Opioid Use ◽

Short Acting ◽

Adjusted Risk ◽

Post Surgery ◽

Percentage Points ◽

Chronic Opioid Use

AbstractObjectiveTo determine the risk of prolonged opioid use in patients receiving tramadol compared with other short acting opioids.DesignObservational study of administrative claims data.SettingUnited States commercial and Medicare Advantage insurance claims (OptumLabs Data Warehouse) January 1, 2009 through June 30, 2018.ParticipantsOpioid-naive patients undergoing elective surgery.Main outcome measureRisk of persistent opioid use after discharge for patients treated with tramadol alone compared with other short acting opioids, using three commonly used definitions of prolonged opioid use from the literature: additional opioid use (defined as at least one opioid fill 90-180 days after surgery); persistent opioid use (any span of opioid use starting in the 180 days after surgery and lasting ≥90 days); and CONSORT definition (an opioid use episode starting in the 180 days after surgery that spans ≥90 days and includes either ≥10 opioid fills or ≥120 days’ supply of opioids).ResultsOf 444 764 patients who met the inclusion criteria, 357 884 filled a discharge prescription for one or more opioids associated with one of 20 included operations. The most commonly prescribed post-surgery opioid was hydrocodone (53.0% of those filling a single opioid), followed by short acting oxycodone (37.5%) and tramadol (4.0%). The unadjusted risk of prolonged opioid use after surgery was 7.1% (n=31 431) with additional opioid use, 1.0% (n=4457) with persistent opioid use, and 0.5% (n=2027) meeting the CONSORT definition. Receipt of tramadol alone was associated with a 6% increase in the risk of additional opioid use relative to people receiving other short acting opioids (incidence rate ratio 95% confidence interval 1.00 to 1.13; risk difference 0.5 percentage points; P=0.049), 47% increase in the adjusted risk of persistent opioid use (1.25 to 1.69; 0.5 percentage points; P<0.001), and 41% increase in the adjusted risk of a CONSORT chronic opioid use episode (1.08 to 1.75; 0.2 percentage points; P=0.013).ConclusionsPeople receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids. Federal governing bodies should consider reclassifying tramadol, and providers should use as much caution when prescribing tramadol in the setting of acute pain as for other short acting opioids.

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Review of nonopioid multimodal analgesia for surgical and trauma patients

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa301 ◽

2020 ◽

Vol 77 (24) ◽

pp. 2052-2063

Author(s):

Stephy George ◽

Meagan Johns

Keyword(s):

Pain Management ◽

Adverse Effects ◽

Multimodal Analgesia ◽

Transitions Of Care ◽

Dose Titration ◽

Patient Specific ◽

Therapeutic Effects ◽

Trauma Patients ◽

Opioid Use ◽

Nonopioid Analgesics

Abstract Purpose Pain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion. Summary In response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care. Conclusion Multimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.

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Buprenorphine Maintenance Therapy Hinders Acute Pain Management in Trauma

The American Surgeon ◽

10.1177/000313481007600417 ◽

2010 ◽

Vol 76 (4) ◽

pp. 397-399 ◽

Cited By ~ 10

Author(s):

Colin J. Harrington ◽

Victor Zaydfudim

Keyword(s):

Pain Management ◽

Maintenance Therapy ◽

Opioid Receptor ◽

Acute Pain ◽

Opiate Receptor ◽

Further Education ◽

Trauma Patients ◽

Μ Opioid Receptor ◽

Higher Doses ◽

Selection Of

Buprenorphine is a mixed opiate receptor agonist-antagonist growing in popularity as an office-based treatment for opioid-dependent patients. It has high affinity, but only partial agonism at the μ-opioid receptor resulting in a ceiling analgesic effect. At higher doses, buprenorphine potentiates antagonism at the κ-opioid receptor. These properties make buprenorphine an effective maintenance treatment for opioid-dependent patients. These same properties, however, can interfere with the management of acute pain in patients on maintenance buprenorphine therapy. We present a case of a young multisystem trauma patient in whom adequate analgesia could not be achieved due to buprenorphine treatment before and through the early course of admission. Discontinuation of buprenorphine allowed for appropriate pain management and successful analgesia. Further education of acute care clinicians about buprenorphine pharmacology and careful selection of patients for buprenorphine maintenance therapy are needed to avoid delays of pain control in trauma patients.

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The effect of a Life Care Specialist on pain management and opioid-related outcomes among patients with orthopedic trauma: study protocol for a randomized controlled trial

Trials ◽

10.1186/s13063-021-05841-1 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Nicholas A. Giordano ◽

Jesse Seilern und Aspang ◽

J‘Lynn Baker ◽

Cammie Wolf Rice ◽

Bailey Barrell ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Substance Use ◽

Pain Management ◽

Controlled Trial ◽

Trauma Patients ◽

Orthopedic Trauma ◽

Life Care ◽

Opioid Use ◽

Randomized Controlled ◽

Care Specialist

Abstract Background Orthopedic trauma patients face complex pain management needs and are frequently prescribed opioids, leaving them at-risk for prolonged opioid use. To date, post-trauma pain management research has placed little emphasis on individualized risk assessments for misuse and systematically implementing non-pharmacologic pain management strategies. Therefore, a community-academic partnership was formed to design a novel position in the healthcare field (Life Care Specialist (LCS)), who will educate patients on the risks of opioids, tapering usage, safe disposal practices, and harm reduction strategies. In addition, the LCS teaches patients behavior-based strategies for pain management, utilizing well-described techniques for coping and resilience. This study aims to determine the effects of LCS intervention on opioid utilization, pain control, and patient satisfaction in the aftermath of orthopedic trauma. Methods In total, 200 orthopedic trauma patients will be randomized to receive an intervention (LCS) or a standard-of-care control at an urban level 1 trauma center. All patients will be assessed with comprehensive social determinants of health and substance use surveys immediately after surgery (baseline). Follow-up assessments will be performed at 2, 6, and 12 weeks postoperatively, and will include pain medication utilization (morphine milligram equivalents), pain scores, and other substance use. In addition, overall patient wellness will be evaluated with objective actigraphy measures and patient-reported outcomes. Finally, a survey of patient understanding of risks of opioid use and misuse will be collected, to assess the influence of LCS opioid education. Discussion There is limited data on the role of individualized, multimodal, non-pharmacologic, behavioral-based pain management intervention in opioid-related risk-mitigation in high-risk populations, including the orthopedic trauma patients. The findings from this randomized controlled trial will provide scientific and clinical evidence on the efficacy and feasibility of the LCS intervention. Moreover, the final aim will provide early evidence into which patients benefit most from LCS intervention. Trial registration ClinicalTrials.govNCT04154384. Registered on 11/6/2019 (last updated on 6/10/2021).

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