Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX.
Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX.
Surgery. 2023 Dec;174(6):1463-1470. doi: 10.1016/j.surg.2023.09.011. Epub 2023 Oct 13.
Screening to identify patients at risk for opioid misuse after trauma is recommended but not commonly used to guide perioperative opioid management interventions. The Multimodal Analgesic Strategies for Trauma trial demonstrated that an opioid-minimizing multimodal pain regimen reduced opioid exposure in a heterogeneous trauma patient population. Here, we assess the efficacy of the Multimodal Analgesic Strategies for Trauma multimodal pain regimen in a critical patient subgroup who screened at high risk for opioid misuse.
The Multimodal Analgesic Strategies for Trauma trial compared an opioid-minimizing multimodal pain regimen (oral acetaminophen, naproxen, gabapentin, lidocaine patch, as-needed opioid) against an original multimodal pain regimen (intravenous followed by oral acetaminophen, 48-hour celecoxib and pregabalin, followed by naproxen and gabapentin, scheduled tramadol, as-needed opioid), in a randomized trial conducted from April 2018 to March 2019. A total of 631 enrolled patients were classified either as low- or high-risk via the Opioid Risk Tool. Bayesian analyses evaluated the moderating influence of Opioid Risk Tool risk (high/low) on the effect of Multimodal Analgesic Strategies for Trauma multimodal pain regimen (versus original) on opioid exposure (morphine milligram equivalents/day), opioids prescribed at discharge, and pain scores.
Multimodal Analgesic Strategies for Trauma multimodal pain regimen effectively reduced morphine milligram equivalents/day in low- and high-Opioid Risk Tool risk groups. Moderation was observed for opioids at discharge and pain scores; Multimodal Analgesic Strategies for Trauma multimodal pain regimen was effective in the high-risk group only (opioids at discharge: 63% vs 77%, relative risk = 0.86, 95% Bayesian credible interval [0.66-1.08], posterior probability (relative risk <1) = 90%; pain scores: b = 3.8, 95% Bayesian credible interval [3.2-4.4] vs b = 4.0, 95% Bayesian credible interval [3.4-4.6], posterior probability (b <0) = 87%).
This study is the first to show the moderating influence of opioid misuse risk on the effectiveness of an opioid-minimizing multimodal pain regimen. The Opioid Risk Tool was useful in identifying high-risk patients for whom the Multimodal Analgesic Strategies for Trauma multimodal pain regimen is recommended for perioperative pain management.
推荐对创伤后有阿片类药物滥用风险的患者进行筛查，以识别此类患者，但目前该方法尚未广泛用于指导围手术期阿片类药物管理干预。多模式镇痛策略治疗创伤试验表明，一种阿片类药物最小化的多模式疼痛方案可减少异质创伤患者人群中的阿片类药物暴露。在这里，我们评估了多模式镇痛策略治疗创伤试验中的多模式疼痛方案在高危阿片类药物滥用的危重症患者亚组中的疗效。
多模式镇痛策略治疗创伤试验比较了一种阿片类药物最小化的多模式疼痛方案（口服对乙酰氨基酚、萘普生、加巴喷丁、利多卡因贴剂、按需使用阿片类药物）与原始的多模式疼痛方案（静脉注射，随后口服对乙酰氨基酚、48 小时塞来昔布和普瑞巴林，随后口服萘普生和加巴喷丁、预定曲马多、按需使用阿片类药物），这是一项于 2018 年 4 月至 2019 年 3 月进行的随机试验。共有 631 名入组患者通过阿片类药物风险工具分为低风险或高风险。贝叶斯分析评估了阿片类药物风险工具风险（高/低）对多模式镇痛策略治疗创伤试验中的多模式疼痛方案（与原始方案相比）对阿片类药物暴露（吗啡毫克当量/天）、出院时开具的阿片类药物以及疼痛评分的调节作用。
多模式镇痛策略治疗创伤试验中的多模式疼痛方案有效地降低了低风险和高阿片类药物风险工具风险组的吗啡毫克当量/天。对出院时的阿片类药物和疼痛评分观察到了调节作用；多模式镇痛策略治疗创伤试验中的多模式疼痛方案仅在高风险组有效（出院时的阿片类药物：63%比 77%，相对风险=0.86，95%贝叶斯可信区间[0.66-1.08]，后验概率（相对风险<1）=90%；疼痛评分：b=3.8，95%贝叶斯可信区间[3.2-4.4]比 b=4.0，95%贝叶斯可信区间[3.4-4.6]，后验概率（b<0）=87%）。
这项研究首次表明，阿片类药物滥用风险对阿片类药物最小化多模式疼痛方案的有效性具有调节作用。阿片类药物风险工具在识别高风险患者方面很有用，建议对这些患者采用多模式镇痛策略治疗创伤试验中的多模式疼痛方案进行围手术期疼痛管理。
