Multi-Modal Analgesic Strategy for Trauma: A Pragmatic Randomized Clinical Trial
- 1 March 2021
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Journal of the American College of Surgeons
- Vol. 232 (3), 241-251e3
- https://doi.org/10.1016/j.jamcollsurg.2020.12.014
Abstract
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 = 0.029; relative risk 0.92; 95% credible interval, 0.86 to 0.99; posterior probability relative risk <1 = 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. ((C) 2020 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)Keywords
Funding Information
- National Center for Advancing Translational Sciences
This publication has 31 references indexed in Scilit:
- An adapted Clavien-Dindo scoring system in trauma as a clinically meaningful nonmortality endpointThe Journal of Trauma and Acute Care Surgery, 2017
- Abuse and Misuse of Pregabalin and GabapentinDrugs, 2017
- Practical Bayesian model evaluation using leave-one-out cross-validation and WAICStatistics and Computing, 2016
- Implementation of a Pediatric Posttonsillectomy Pain Protocol in a Large Group PracticeOtolaryngology -- Head and Neck Surgery, 2016
- Lidocaine Skin Patch (Lidopat® 5%) Is Effective in the Treatment of Traumatic Rib Fractures: A Prospective Double-Blinded and Vehicle-Controlled StudyMedical Principles and Practice, 2015
- Multimodal analgesia versus traditional opiate based analgesia after cardiac surgery, a randomized controlled trialJournal of Cardiothoracic Surgery, 2014
- Rank-Based Analyses of Stratified Experiments: Alternatives to the van Elteren TestThe American Statistician, 2010
- Randomized, Double-Blind, Placebo-Controlled Trial Using Lidocaine Patch 5% in Traumatic Rib FracturesJournal of the American College of Surgeons, 2010
- Bayesian statistical inference enhances the interpretation of contemporary randomized controlled trialsJournal of Clinical Epidemiology, 2009
- Rank Score TestsJournal of the American College of Cardiology, 2006