Age-related Opioid Exposure in Trauma: A Secondary Analysis of the Multimodal Analgesia Strategies for Trauma (MAST) Randomized Trial

Abstract

Objective: Evaluate the effect of age on opioid consumption after traumatic injury. Summary Background Data: Older trauma patients receive fewer opioids due to decreased metabolism and increased complications, but adequacy of pain control is unknown. We hypothesized that older trauma patients require fewer opioids to achieve adequate pain control. Methods: A secondary analysis of the multimodal analgesia strategies for trauma Trial evaluating the effectiveness of 2 multimodal pain regimens in 1561 trauma patients aged 16 to 96 was performed. Older patients (≥55 years) were compared to younger patients. Median daily oral morphine milligram equivalents (MME) consumption, average numeric rating scale pain scores, complications, and death were assessed. Multivariable analyses were performed. Results: Older patients (n = 562) had a median age of 68 years (interquartile range 61–78) compared to 33 (24–43) in younger patients. Older patients had lower injury severity scores (13 [9–20] vs 14 [9–22], P = 0.004), lower average pain scores (numeric rating scale 3 [1–4] vs 4 [2–5], P < 0.001), and consumed fewer MME/day (22 [10–45] vs 52 [28–78], P < 0.001). The multimodal analgesia strategies for trauma multi-modal pain regimen was effective at reducing opioid consumption at all ages. Additionally, on multivariable analysis including pain score adjustment, each decade age increase after 55 years was associated with a 23% reduction in MME/day consumed. Conclusions: Older trauma patients required fewer opioids than younger patients with similar characteristics and pain scores. Opioid dosing for post-traumatic pain should consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control.

Travma Hastalarında Multimodal Analjezi ve Ağrı Değerlendirme Kayıtlarının İncelenmesi

“…7,8,14 Burton et al 15 determined that multimodal pain management reduces the number of opioids used and the prescribed dose in patients with thoracic trauma. Similarly, Hatton et al 16 found that multimodal pain management applied in elderly patients decreased the number of opioids used and, thus, the complications. The most important reason is that the multiple analgesia met-hod is thought to provide effective analgesia because it affects both peripheral and central pain sources and causes fewer side effects at low doses.…”

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

“…The multimodal analgesic approach (MMA) or "balanced analgesia" was introduced with the aim of decreasing the exposure to opioids, to address acute pain effectively, and enhance recovery after surgical procedure and trauma. It is defined as the integrated use of multiple strategies including systemic analgesics, regional analgesic techniques, and non-pharmacological interventions to affect peripheral and/or central nervous system sites in the pain pathway with the main aim of achieving a synergistic effect of the various classes of drugs used at lower analgesic doses [344][345][346][347][348][349]. MMA provides the use of: (1) analgesics, including opioids, nonopioid analgesics (such as acetaminophen and NSAIDs), the gabapentinoids (gabapentin and pregabalin), serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, and N-methyl-d-aspartate (NMDA) receptor antagonists; (2) neuraxial (epidural and intrathecal) analgesia; (3) peripheral nerve blocks; and (4) intraarticular and wound infiltration with local anaesthetics.…”

“…The synergy created when multimodal regimens are used to target discrete components of the peripheral and central pain pathways leads to effective analgesia at lower opioid dosing, reducing related risk and producing fewer adverse effects [343,344,349] MMA should be individualized in a muldisciplinary approach according to the patient; type of pain; mechanism of pain (inflammatory or neuropathic); type of surgical procedure; location of pain; expected duration of pain. Because of their opioidsparing effects, multimodal strategies are useful and safe for elderly patients [345,346].…”

“…Opioid dosing for post-traumatic pain should therefore consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control [346]. Neuraxial and peripheral regional anesthesia Regional analgesia is a crucial part of MMA.…”