Via Research Recognition Day 2024 VCOM-Carolinas

Educational Reports

NARCOTIC CONSUMPTION ANALYSIS AMONG SEVERELY INJURED AND ADVANCED AGED TRAUMA PATIENTS Nicholas G. Minner OMS-III, Jacob Steiniger BS, Siena Lombardozzi, Joel M L Biester MD, Caleb J Mentzer DO, Charles E Morrow MD, Michael G Mount DO, Brian C Thurston MD, Bari S Compton MSN, Robert Steed, Sarah W Frye PharmD, TJ Mack MSN RN, Kristine A Lombardozzi MD Edward Via College of Osteopathic Medicine, Spartanburg, South Carolina Division of Surgery, Spartanburg Regional Healthcare System, Spartanburg, South Carolina, Spartanburg County Introduction Results Discussion

Conclusion The Institutional Review Board at Spartanburg Regional Medical Center approval protocol [1934404-1] and [1934402-1] on July 26,2022. 1. Manchikanti L, Sanapati J, Benyamin RM, Atluri S, Kaye AD, Hirsch JA. Reframing the prevention strategies of the opioid crisis: focusing on prescription opioids, fentanyl, and heroin epidemic. Pain Physician . 2018;21(4):309-326. doi:10.36076/ppj.2018.4.309 2. 2020-12-31 08:51 | Archive of HHS.gov. Accessed October 29, 2023. https://public3.pagefreezer.com/browse/HHS.gov/31-12 2020T08:51/https://www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html 3. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ . 2014;348:g1251. doi:10.1136/bmj.g1251 4. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Intern Med . 2016;176(9):1286-1293. doi:10.1001/jamainternmed.2016.3298 5. Alghnam S, Castillo R. Traumatic injuries and persistent opioid use in the USA: findings from a nationally representative survey. Inj Prev . 2017;23(2):87-92. doi:10.1136/injuryprev-2016-042059 6. Oderda GM, Lake J, Rüdell K, Roland CL, Masters ET. Economic burden of prescription opioid misuse and abuse: A systematic review. J Pain Palliat Care Pharmacother . 2015;29(4):388-400. doi:10.3109/15360288.2015.1101641 7. von Oelreich E, Eriksson M, Brattström O, et al. Risk factors and outcomes of chronic opioid use following trauma. Br J Surg . 2020;107(4):413-421. doi:10.1002/bjs.11507 8. Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors | Guidance Portal. Accessed October 29, 2023. https://www.hhs.gov/guidance/document/opioid-oral-morphine-milligram-equivalent-mme-conversion-factors-0 9. Opioid Abuse in the U.S. and HHS Actions to Address Opioid-Drug Related Overdoses and Deaths | ASPE. Accessed October 29, 2023. https://aspe.hhs.gov/reports/opioid-abuse-us-hhs-actions-address-opioid-drug-related-overdoses-deaths 10. Helmerhorst GTT, Vranceanu A-M, Vrahas M, Smith M, Ring D. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am . 2014;96(6):495-499. doi:10.2106/JBJS.L.01406 11. Brady KT, McCauley JL, Back SE. Prescription opioid misuse, abuse, and treatment in the united states: an update. Am J Psychiatry . 2016;173(1):18-26. doi:10.1176/appi.ajp.2015.15020262 12. Biester JML, Mentzer CJ, Caswell SR, et al. Multi-modal Pain Control Protocol Decreases Narcotic Consumption in an Inpatient Trauma Population. Am Surg . 2022;88(5):968-972. doi:10.1177/00031348211058641 Among the two populations studied using MMPC, the more severely injured population displayed a statistically significant decrease in the amount of opioid consumption while demonstrating statistical improvement in pain control compared to the SPM group. However, in the advanced age trauma population (≥55 years) no difference in pain control or opioid consumption was identified between the multimodal approach and SPM. MMPC is an effective strategy for reducing opioid consumption in some trauma populations, demonstrated in severely injured patients, however, different strategies will be required to address special patient populations. Acknowledgements & References The severely injured population had a reduction of opioid consumption was efficacious despite patients with rib and long bone fractures and for intubated patients, who often require IV opioids as a part of their pain management strategies while in the ICU. While other multimodal pain control studies have displayed reductions in opioid consumption among patients with fractures, it was surprising to see the magnitude of the MMPC’s impact on this more severely injured group of patients. The advanced age population showed no difference between opioid consumption and pain scores when comparing the SPM and MMPC groups. There are two likely factors contributing to the similar pain scores and opioid consumption among the two groups: injury severity and age. It is important to note that this population was less severely injured. With less severe mechanisms of injury and less severe injuries, it was expected that overall pain control needs would be lower. Lower baseline pain scores likely explain reduced opioid consumption regardless of which of the group to which the patient was assigned. Another factor that may have contributed to equivalent opioid utilization among the MMPC and SPM group is age related prescribing practices. In most cases, drugs with severe CNS depressant effects like opioids have always been cautiously prescribed to advanced age patients due to the adverse side effects.

Opioids have long served as a fundamental component in the management of acute pain following injuries, with their use extending to post-surgery and traumatic situations. The utilization of opioids in these contexts has been identified as a contributing factor to the development of opioid dependence. Prescription drugs served as the introduction to opioids for 75% of patients receiving treatment for heroin addiction. 1,2 Approximately 6% of opioid-naïve patients develop persistent opioid use after surgery, 3,4 with rates soaring to 15-28% in trauma cases. 5,6 A study found that chronic opioid use following traumatic injury is associated with increased mortality within 18 months of exposure to opioids. 7 In 2015, the U.S. Department of Health and Human Services prioritized combating opioid abuse, particularly focusing on improving prescribing practices. 8–10 Notably, older patients, due to unique opioid metabolism, face higher risks, necessitating tailored approaches within the broader context of pain management. 11 In 2017, the Trauma/Acute Care Surgery surgeons at Spartanburg Medical Center instituted an opioid minimizing, multimodal pain control (MMPC) protocol. Five different classes of pain medication: a central prostaglandin inhibitor (acetaminophen), a non-steroidal anti-inflammatory drug (NSAID), a gabapentinoid (gabapentin), a skeletal muscle relaxant, and a local anesthetic (lidocaine patch) are given in a scheduled fashion in combination with oral or intravenous (IV) opioids on an as needed basis. An earlier study of the MMPC protocol at the community-based, level 1 trauma center found a significant reduction in opioid consumption while providing similar pain control in the inpatient trauma population. 12 In the previous study, while not statistically significant, there was a trend towards higher age in the MMPC group. Additionally, the MMPC group was less severely injured (Injury Severity Score (ISS) 10 vs 8, p=0.0196) than the STP group. We hypothesize MMPC will reduce opioid consumption in both the advanced aged and more severely injured trauma populations while still providing adequate pain control. After obtaining institutional review board approval at Spartanburg Regional Healthcare System, we performed two single-center, retrospective comparative effectiveness trials. Patients meeting the inclusion criteria were randomly selected from the trauma database to create the study groups. Power analysis determined 30 patients in each group is needed to detect a 10% difference between populations with 95% confidence. Advanced age group was defined as patients ≥55 years old. The severely injured group was defined as patients were defined as ≥18 years old with ≥15 ISS. Standard treatment protocol (STP) patients were admitted between January 2014 and December 2015 while the MMPC group was admitted from January 2018 to December 2019. MMPC was compared to STP in the advanced age groups and between the severely injured groups. Primary outcomes were total opioid utilization per day, calculated in morphine milliequivalents (MME), and median daily pain scores. Secondary outcomes include unplanned ICU admission, ileus, unplanned intubations, use of opioid reversal agent, death, ventilator days, intensive care unit length of stay, discharge disposition and hospital days. Methods

The severely injured (ISS > 15) adults in the MMPC group showed a significant threefold decrease in opioid consumption (30 MME/d vs 90.3 MME/d, P < 0.001) and significantly lower pain scores (5/10 vs 6/10, P<0.001) than the SPM group (Table 1). Demographics including age, gender, and race showed no difference between MMPC and SPM. There was no difference in the ISS between MMPC and SPM (21.5 vs 21, P > 0.7575). The number of hospital days, ICU days, and ventilator days were similar. There was no difference in the discharge disposition. The two groups were similar in the following outcomes: unplanned admission to ICU, ileus, unplanned intubation, use of reversal agent, presence of long bone fractures, and rib fractures. In the advance age groups (>55 years old), there was no significant difference between the MMPC and the SPM groups in opioid consumption (15 MME/d vs 15 MME/d, P = 0.9744) or pain scores (4/10 pain vs 5/10 pain, P = 0.5526) (Table 1). Advanced age MMPC and SPM groups demographics including age, gender, and race showed no difference. The median age was 71.5 and 73.5, P = 0.7169. There was no difference in the ISS between MMPC and SPM (9 vs 9, P = 0.4889). The number of hospital days, ICU days, and ventilator days were similar. There was no difference in the discharge disposition. The two groups were similar in the following outcomes: unplanned admission to ICU, ileus, unplanned intubation, use of reversal agent, long bone fractures, and rib fractures.

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2024 Research Recognition Day