Pain Trajectories Following Subarachnoid Hemorrhage are Associated with Continued Opioid Use at Outpatient Follow-up

Abstract

Background Subarachnoid hemorrhage (SAH) is characterized by the worst headache of life and associated with long-term opioid use. Discrete pain trajectories predict chronic opioid use following other etiologies of acute pain, but it is unknown whether they exist following SAH. If discrete pain trajectories following SAH exist, it is uncertain whether they predict long-term opioid use. We sought to characterize pain trajectories after SAH and determine whether they are associated with persistent opioid use. Methods We reviewed pain scores from patients admitted to a single tertiary care center for SAH from November 2015 to September 2019. Group-based trajectory modeling identified discrete pain trajectories during hospitalization. We compared outcomes across trajectory groups using χ 2 and Kruskal–Wallis tests. Multivariable regression determined whether trajectory group membership was an independent predictor of long-term opioid use, defined as continued use at outpatient follow-up. Results We identified five discrete pain trajectories among 305 patients. Group 1 remained pain free. Group 2 reported low scores with intermittent spikes and slight increase over time. Group 3 noted increasing pain severity through day 7 with mild improvement until day 14. Group 4 experienced maximum pain with steady decrement over time. Group 5 reported moderate pain with subtle improvement. In multivariable analysis, trajectory groups 3 (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5–8.3) and 5 (OR 8.0; 95% CI 3.1–21.1), history of depression (OR 3.6; 95% CI 1.3–10.0) and racial/ethnic minority (OR 2.3; 95% CI 1.3–4.1) were associated with continued opioid use at follow-up (median 62 days following admission, interquartile range 48–96). Conclusions Discrete pain trajectories following SAH exist. Recognition of pain trajectories may help identify those at risk for long-term opioid use.

Safety and efficacy of peripheral nerve blocks to treat refractory headaches after aneurysmal subarachnoid hemorrhage – A pilot observational study

“…Research on novel treatment options for HASH is greatly needed. An effective treatment strategy for HASH likely needs to be multifaceted considering complex pathophysiology, individual pain perception and pain trajectories (10). Although exact mechanism of HASH has not been elucidated, current evidence suggests that blood in the subarachnoid space in the brain and neck can mechanically stretch and irritate trigeminovascular and greater occipital afferent neurons resulting in headache and meningismus (16).…”

“…All patients were followed up at 1 week after enrollment, so we were able to show there was still benefit at that time point. Importantly, there is growing research that patients with HASH follow discrete pain trajectories ( 10 ), and pain trajectories can predict generation of chronic pain ( 9 , 33 ). In our preliminary study, we found that PNB appeared to alter this trajectory immediately after administration, therefore it is plausible that it may alter and development of chronic HASH in some patients.…”

“…Despite high prevalence and potential deleterious effects of HASH, there is a lack of evidence-based treatment modalities for this disease with only 9% of providers indicating use of a standardized approach for HASH management, for which opioids remain the mainstay ( 9 ). Pain trajectories following aSAH are associated with continued opioid use at outpatient follow up ( 10 ), which contributes to the ongoing opioid epidemic. Pterygopalatine fossa blockade, recently reported by Smith et al have recently emerged as a therapeutic option ( 11 ), but there continues to be an enormous need for an effective opioid-sparing treatment options in these patients, and more research is needed in this area.…”

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

“…In the absence of data-proven effective headache management strategies, lack of updated guidelines for such management, and incomplete understanding of trajectories of post-SAH headache [17,18], we hypothesized that signi cant practice variability exists in the management of acute post-SAH headaches in the critical care setting. The objective of this study is to examine the variety of different approaches to manage headaches in non-traumatic SAH patients during hospitalization and at discharge from the hospital with an emphasis on characterizing opioid administration and spanning international practice.…”

Adjunctive virtual reality pain relief following traumatic injury: protocol for a randomised within-subjects clinical trial

“…Among soldiers returning from active duty who have a TBI diagnosis, nearly 60% are prescribed an opioid during the postdeployment year 21 22. In a study of patients with acute neurological injury suffering from aneurysmal subarachnoid haemorrhage, opioid use was associated with discrete pain trajectories, pain burden and craniotomy 23 24. Opioid sparing during hospitalisations with acute pain is an important component of addressing the current opioid epidemic 25.…”