Modified pain management strategy reduces opioid exposure to trauma patients

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 American College of Surgeons.

"The research shows us that seriously injured people with acute pain can effectively be treated with an opioid-minimizing strategy," said John Harvin, MD, MS, associate professor in the Department of Surgery at McGovern Medical School at UTHealth and first and corresponding author of the study. "Narcotics are not the mainstay of therapy for acute pain." Harvin is also an attending trauma surgeon at the Red Duke Trauma Institute.

The randomized study assessed two different combinations of various non-opioid pain relievers in a total of 1,561 patients. Researchers sought to determine which combination could better reduce opioid exposure in the hospital and after discharge for patients with acute trauma, like pelvic and rib fractures.

One opioid-minimizing treatment strategy is known as the "original," because in 2013, Harvin's team began administering it as a first-line pain regimen and prescribing opioids only as needed. It contains more potent medications including intravenous and oral acetaminophen, celecoxib, pregabalin, naproxen, gabapentin, tramadol (a narcotic), and as needed, oxycodone. This strategy reduced opioid exposure by 31%, but the tramadol made it not opioid-minimizing and it involved more expensive drugs that are not widely available.

In the search for a more ideal strategy, the team created the MAST regimen, named after the study, which is called Multi-Modal Analgesic Strategies in Trauma. It included much more generic and affordable medications: oral acetaminophen, naproxen, gabapentin, lidocaine patches, and as needed, opioids. The only drug that requires a prescription is gabapentin.

Patients randomized to the MAST regimen received less opioid exposure per day -- 34 morphine milligram equivalents (MME) compared to 48, and were more likely to be discharged without an opioid prescription, including tramadol (38% versus 33%). No clinically significant difference in pain scores were seen.

"Our first hypothesis was that the original regimen would provide better acute pain control because those medications theoretically should have performed better. We thought if we could control acute pain better upfront then we could use less narcotics overall, but the MAST regimen achieved equal levels of pain control and overall reduced opioid exposure, likely because it only included opioids as needed. Narcotics do not need to be the first line of therapy for acute pain control," Harvin said.

The National Institute on Drug Abuse reports 128 people die every day from opioid overdose, based on data from 2018. 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, with June peaking at 116 calls. That's up from the 60 calls per month they averaged in 2018, and 80 in 2019.

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

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

Since then, many health providers have relied on opioids to manage acute pain. While prescription drugs from surgery aren't the only cause of opioid addiction, they are a big contributor, Harvin said.

"The best way to decrease someone's risk for long-term use is to minimize their exposure during hospitalization and at discharge, and we now know there are excellent non-opioid medications available that effectively treat pain. We know that culture change will take time and effort, but we're excited to be learning how to best leverage opioid-minimizing drugs to improve care, and to offer a new model that can be adopted by any trauma center."

"Although there is still much work to be done to optimize and to individualize pain regimens for our diverse trauma population, this trial demonstrates the ability of Level 1 trauma centers to rapidly and efficiently learn from patients using rigorous research methodology while simultaneously improving patient care," said Lillian Kao, MD, MS, professor of surgery with McGovern Medical School and senior author of the study. "This type of continuous learning and improvement is facilitated by a close relationship between the academic center (UTHealth), the trauma center (Red Duke Trauma Institute), and our research infrastructure (Center for Translational Injury Research)." Kao is also the division director of acute care surgery at Memorial Hermann-TMC.

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