Optimizing Pain Control and Minimizing Opioid Use in Trauma Patients

2021 ◽  
Vol 32 (1) ◽  
pp. 89-104
Author(s):  
Shanna Fortune ◽  
Jennifer Frawley
Keyword(s):  
Virtual Reality ◽  
Pain Control ◽  
Complementary Therapies ◽  
Treatment Effectiveness ◽  
Trauma Patients ◽  
Mirror Therapy ◽  
Opioid Use ◽  
Trauma Population ◽  
Nonopioid Analgesics ◽  
Inflammatory Drugs

Adverse effects of opioids and the ongoing crisis of opioid abuse have prompted providers to reduce prescribing opioids and increase use of multiple nonpharmacologic therapies, nonopioid analgesics, and co-analgesics for pain management in trauma patients. Nonopioid agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, central α2 agonists, and lidocaine, can be used as adjuncts or alternatives to opioids in the trauma population. Complementary therapies such as acupuncture, virtual reality, and mirror therapy are modalities that also may be helpful in reducing pain. Performing pain assessments is fundamental to identify pain and evaluate treatment effectiveness in the critically ill trauma patient. The efficacy, safety, and availability of opioid-sparing therapies and multimodal pain regimens are reviewed.

Review of nonopioid multimodal analgesia for surgical and trauma patients

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.

scholarly journals Stemming the Tide of Opioid Addiction—Dramatic Reductions in Postoperative Opioid Requirements Through Preoperative Education and a Standardized Analgesic Regimen

2019 ◽  
Vol 185 (3-4) ◽  
pp. 436-443 ◽  
Author(s):  
Rowan R Sheldon ◽  
Jessica B Weiss ◽  
Woo S Do ◽  
Dominic M Forte ◽  
Preston L Carter ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Pain Management ◽  
Postoperative Pain ◽  
Pain Control ◽  
Inclusion Criteria ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Management Protocol ◽  
Patient Reported ◽  
Nonopioid Analgesics

Abstract Introduction Surgery is a known gateway to opioid use that may result in long-term morbidity. Given the paucity of evidence regarding the appropriate amount of postoperative opioid analgesia and variable prescribing education, we investigated prescribing habits before and after institution of a multimodal postoperative pain management protocol. Materials and Methods Laparoscopic appendectomies, laparoscopic cholecystectomies, inguinal hernia repairs, and umbilical hernia repairs performed at a tertiary military medical center from 01 October 2016 until 30 September 2017 were examined. Prescriptions provided at discharge, oral morphine equivalents (OME), repeat prescriptions, and demographic data were obtained. A pain management regimen emphasizing nonopioid analgesics was then formulated and implemented with patient education about expected postoperative outcomes. After implementation, procedures performed from 01 November 2017 until 28 February 2018 were then examined and analyzed. Additionally, a patient satisfaction survey was provided focusing on efficacy of postoperative pain control. Results Preprotocol, 559 patients met inclusion criteria. About 97.5% were provided an opioid prescription, but prescriptions varied widely (256 OME, standard deviation [SD] 109). Acetaminophen was prescribed often (89.5%), but nonsteroidal anti-inflammatory drug (NSAID) prescriptions were rare (14.7%). About 6.1% of patients required repeat opioid prescriptions. After implementation, 181 patients met inclusion criteria. Initial opioid prescriptions decreased 69.8% (77 OME, SD 35; P < 0.001), while repeat opioid prescriptions remained statistically unchanged (2.79%; P = 0.122). Acetaminophen prescribing rose to 96.7% (P = 0.002), and NSAID utilization increased to 71.0% (P < 0.001). Postoperative survey data were obtained in 75 patients (41.9%). About 68% stated that they did not use all of the opioids prescribed and 81% endorsed excellent or good pain control throughout their postoperative course. Conclusions Appropriate preoperative counseling and utilization of nonopioid analgesics can dramatically reduce opioid use while maintaining high patient satisfaction. Patient-reported data suggest that even greater reductions may be possible.

scholarly journals Analgesics

2020 ◽  
Author(s):  
Mihai Botea
Keyword(s):  
Acute Pain ◽  
World Health ◽  
Trauma Patients ◽  
Who Analgesic Ladder ◽  
Patients With Cancer ◽  
Nonopioid Analgesics ◽  
Inflammatory Drugs ◽  
The Moment ◽  
Health Organization ◽  
Pain Management Strategy

It is the responsibility of the professional care team to develop an effective person-centred Pain Management strategy which appropriately assesses patients, analyses the results of the assessment and devises a person centred plan to manage pain while allowing the person to remain as independent and functional as possible. The medications useful in treating acute pain are similar to those used in treating other types of pain. The World Health Organization (WHO) analgesic ladder developed for treating patients with cancer pain also provides a useful approach to treat acute pain. At the lowest level (mild pain) are recommended nonopioid analgesics such as paracetamol or/plus nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g. ibuprophen). Such drugs have an analgesic ceiling; above a certain dose, no further analgesia is expected. For moderate pain, are recommended combining paracetamol and/or a NSAID with an opioid (a weak opoid). The inclusion of paracetamol limits the amount of opoids that should be used within 24 hour period, with many benefits which will be discussed later in the chapter. For severe level of pain, a strong opoid such as morphine is a better choice; such opoids have no analgesic ceiling. Most postoperative or trauma patients initially respond better to a morphine-equivalent opoid. At the moment when the patient is eating and drinking, a combination of oral analgesics including opoids and paracetamol plus/minus NSAID are most of the time an adequate choice.

Early Use of a Chest Trauma Protocol in Elderly Patients with Rib Fractures Improves Pulmonary Outcomes

2019 ◽  
Vol 85 (3) ◽  
pp. 288-291 ◽  
Author(s):  
Katherine M. Kelley ◽  
Jessica Burgess ◽  
Leonard Weireter ◽  
Timothy J. Novosel ◽  
Krista Parks ◽  
...  
Keyword(s):  
Noninvasive Ventilation ◽  
Chest Trauma ◽  
Standard Procedure ◽  
Rib Fractures ◽  
Trauma Patients ◽  
Ctrl Group ◽  
Multiple Rib Fractures ◽  
Trauma Population ◽  
Inflammatory Drugs ◽  
One Year

Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our “elderly” (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.

Association of Opioid Quantity and Caregiver Education with Pain Control after Pediatric Tonsillectomy

2020 ◽  
Vol 162 (5) ◽  
pp. 746-753
Author(s):  
Calista M. Harbaugh ◽  
Gracia Vargas ◽  
Kenneth R. Sloss ◽  
Lauren A. Bohm ◽  
Karen A. Cooper ◽  
...  
Keyword(s):  
Pain Control ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Guideline Implementation ◽  
Care Practice ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Caregiver Education ◽  
Nonopioid Analgesics ◽  
Control Education

Objective To examine whether a service guideline reducing postoperative opioid prescription quantities and caregiver-reported education to use nonopioid analgesics first are associated with caregiver-reported pain control after pediatric tonsillectomy. Study Design Prospective cohort study (July 2018–April 2019). Setting Pediatric otolaryngology service at a tertiary academic children’s hospital. Subjects and Methods Caregivers of patients aged 1 to 11 years undergoing tonsillectomy (N = 764) were surveyed 7 to 21 days after surgery regarding pain control, education to use nonopioid analgesics first, and opioid use. Respondents who were not prescribed opioids or had missing data were excluded. Logistic regression modeled caregiver-reported pain control as a function of service guideline implementation (December 2018) recommending 20 rather than 30 doses for postoperative opioid prescriptions and caregiver-reported analgesic education, adjusting for patient demographics. Results Among 430 respondents (56% response), 387 patients were included. The sample was 43% female with a mean age of 5.0 years (SD, 2.5). Pain control was reported as good (226 respondents, 58%) or adequate/poor (161 respondents, 42%). Mean opioid prescription quantity was 27 doses (SD, 7.9) before and 21 doses (SD, 6.1) after guideline implementation ( P < .001). Education to use nonopioids first was reported by 308 respondents (80%). In regression, prescribing guideline implementation was not associated with pain control (adjusted odds ratio, 1.3; 95% CI, 0.9-2.0; P = .22), but caregiver-reported education to use nonopioids first was associated with a higher odds of good pain control (adjusted odds ratio, 1.9; 95% CI, 1.1-3.2; P = .02). Conclusion Caregiver education to use nonopioid analgesics first may be a modifiable health care practice to improve pain control as postoperative opioid prescription quantities are reduced.

Continuous Infusion Nonsteroidal Anti-Inflammatory Drugs for Perioperative Pain Management

2016 ◽  
Vol 31 (1) ◽  
pp. 66-81 ◽  
Author(s):  
Meredith L. Howard ◽  
Alex N. Isaacs ◽  
Sarah A. Nisly
Keyword(s):  
Adverse Effects ◽  
Continuous Infusion ◽  
Pain Control ◽  
Surgical Patient ◽  
Opioid Use ◽  
Medline Search ◽  
Perioperative Pain ◽  
Alternative Modality ◽  
Inflammatory Drugs ◽  
Anti Inflammatory

Purpose: To review the use of continuous infusion (CI) nonsteroidal anti-inflammatory drugs (NSAIDs) as an alternative modality for pain control in surgical patient populations. Methods: A PubMed and MEDLINE search was conducted from 1964 through February 2016 using the following search terms alone or in combinations: continuous, infusion, nonsteroidal anti-inflammatory drug, diclofenac, ibuprofen, indomethacin, ketoprofen, ketorolac, and surgery. All English-language, prospective and retrospective, adult and pediatric studies evaluating intravenous or intramuscular CI NSAIDs for surgical pain were evaluated for inclusion in this review. Results: Twenty four prospective and retrospective publications evaluating CI NSAIDs were identified: 12 in abdominal surgery, 7 in orthopedic surgery, and 5 in pediatric surgery. Specific CI NSAIDs utilized included diclofenac, indomethacin, ketoprofen, and ketorolac. Most studies compared the CI NSAID to placebo or an alternative analgesic and evaluated pain control, supplemental opioid use, and related adverse effects. In these surgical populations, CI NSAIDs decreased opioid consumption, alongside provision of adequate pain control. While long-term adverse effects were rarely collected, a decrease in nausea and sedation was often seen with the CI NSAID groups. Conclusions: In the abdominal, orthopedic, and pediatric surgical populations, CI NSAIDs represent a feasible alternative modality for perioperative pain control.

scholarly journals Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy

2021 ◽  
Vol 18 (5) ◽  
pp. 2654
Author(s):  
Roxana Steliana Miclaus ◽  
Nadinne Roman ◽  
Ramona Henter ◽  
Silviu Caloian
Keyword(s):  
Virtual Reality ◽  
Muscle Strength ◽  
Lower Extremity ◽  
Range Of Motion ◽  
Control Group ◽  
Mirror Therapy ◽  
Cohen’S D ◽  
Cohen's D ◽  
Experimental Group ◽  
Post Therapy

More innovative technologies are used worldwide in patient’s rehabilitation after stroke, as it represents a significant cause of disability. The majority of the studies use a single type of therapy in therapeutic protocols. We aimed to identify if the association of virtual reality (VR) therapy and mirror therapy (MT) exercises have better outcomes in lower extremity rehabilitation in post-stroke patients compared to standard physiotherapy. Fifty-nine inpatients from 76 initially identified were included in the research. One experimental group (n = 31) received VR therapy and MT, while the control group (n = 28) received standard physiotherapy. Each group performed seventy minutes of therapy per day for ten days. Statistical analysis was performed with nonparametric tests. Wilcoxon Signed-Rank test showed that both groups registered significant differences between pre-and post-therapy clinical status for the range of motion and muscle strength (p < 0.001 and Cohen’s d between 0.324 and 0.645). Motor Fugl Meyer Lower Extremity Assessment also suggested significant differences pre-and post-therapy for both groups (p < 0.05 and Cohen’s d 0.254 for the control group and 0.685 for the experimental group). Mann-Whitney results suggested that VR and MT as a therapeutic intervention have better outcomes than standard physiotherapy in range of motion (p < 0.05, Cohen’s d 0.693), muscle strength (p < 0.05, Cohen’s d 0.924), lower extremity functionality (p < 0.05, Cohen’s d 0.984) and postural balance (p < 0.05, Cohen’s d 0.936). Our research suggests that VR therapy associated with MT may successfully substitute classic physiotherapy in lower extremity rehabilitation after stroke.

scholarly journals The Association between Implementation an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

2021 ◽  
Author(s):  
Jennifer A. McCoy ◽  
Sarah Gutman ◽  
Rebecca F. Hamm ◽  
Sindhu K. Srinivas
Keyword(s):  
Cesarean Delivery ◽  
Pain Control ◽  
Enhanced Recovery ◽  
Median Number ◽  
Baseline Survey ◽  
Quality Improvement Initiative ◽  
Opioid Use ◽  
Pain Scores ◽  
Patient Reported ◽  
Hospital Patients

Objective This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. Study Design We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. Results Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90–195] PRE to 114 [range: 45–168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5–8] vs. POST 5 [range: 3–7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16–30] vs. POST 17.5 [range: 4–25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2–6] vs. POST 3[range: 1–5], p = 0.03). Conclusion Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. Key Points

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