Multi-Modal Analgesic Strategy for Trauma: A Pragmatic Randomized Clinical Trial

Abstract

for the MAST Study Group BACKGROUND: An effective strategy to manage acute pain and minimize opioid exposure is needed for injured patients. In this trial, we aimed to compare 2 multimodal pain regimens (MMPRs) for minimizing opioid exposure and relieving acute pain in a busy, urban trauma center. METHODS:This was an unblinded, pragmatic, randomized, comparative effectiveness trial of all adult trauma admissions except vulnerable patient populations and readmissions. The original MMPR (IV administration, followed by oral, acetaminophen, 48 hours of celecoxib and pregabalin, followed by naproxen and gabapentin, scheduled tramadol, and as-needed oxycodone) was compared with an MMPR of generic medications, termed the Multi-Modal Analgesic Strategies for Trauma (MAST) MMPR (ie oral acetaminophen, naproxen, gabapentin, lidocaine patches, and as-needed opioids). The primary endpoint was oral morphine milligram equivalents (MMEs) per day and secondary outcomes included total MMEs during hospitalization, opioid prescribing at discharge, and pain scores. RESULTS:During the trial, 1,561 patients were randomized, 787 to receive the original MMPR and 774 to receive the MAST MMPR. There were no differences in demographic characteristics, injury characteristics, or operations performed. Patients randomized to receive the MAST MMPR had lower MMEs per day (34 MMEs/d; interquartile range 15 to 61 MMEs/d vs 48 MMEs/d; interquartile range 22 to 74 MMEs/d; p < 0.001) and fewer were prescribed opioids at discharge (62% vs 67%; p ¼ 0.029; relative risk 0.92; 95% credible interval, 0.86 to 0.99; posterior probability relative risk <1 ¼ 0.99). No clinically significant difference in pain scores were seen. CONCLUSIONS:The MAST MMPR was a generalizable and widely available approach that reduced opioid exposure after trauma and achieved adequate acute pain control.

Pain management on a trauma service: a crisis reveals opportunities

“…In fields such as general surgery, protocols have been developed to establish procedure specific guidelines for opioid prescribing 7 8. Since the time that this study was performed, some multimodal pain guidelines have been established in trauma surgery 12–14. Indeed, one could argue that the recent prospective trial from Harvin et al 13 demonstrates success of robust multimodal pain therapy across all types of patients, making it a moot issue.…”

“…Since the time that this study was performed, some multimodal pain guidelines have been established in trauma surgery 12–14. Indeed, one could argue that the recent prospective trial from Harvin et al 13 demonstrates success of robust multimodal pain therapy across all types of patients, making it a moot issue. However, they tended to enroll multisystem injured patients in their trial so it might be worthwhile to prospectively study more isolated injury types.…”

Ketamine for Acute Pain After Trauma: KAPT Trial

“…Trauma patients at the RDTI are initially prescribed with an opioid-minimizing MMPR informed by the MAST trial. 3 This regimen consists of four different classes of medications given in a scheduled fashion: acetaminophen, naproxen, gabapentin, and lidocaine patch(s). Tramadol or oxycodone are administered as needed for additional pain control.…”

“…The generic MMPR resulted in lower in-hospital opioid exposure and opioid prescribing without a clinically signi cant increase in pain scores. 3 The MAST MMPR replaced the original MMPR as usual care locally. Despite these improvements, short-term opioid administration for acute pain continues to be associated with a small but substantial risk of persistent opioid use.…”

“…In both the MAST trial and a multicenter observational study, in-hospital opioid exposure was highest within the rst 72 hours after admission. 3,5 While new medications and non-medicinal interventions to minimize opioid exposure are needed, patients are still arriving to trauma centers with acute pain that must be treated. Thus, continued re nement and improvement of our MMPR is needed.…”