T4 Impact of Opioid-Minimizing Pain Protocols after Burn Injury

Abstract

Abstract Introduction Traditionally, opioids have been the mainstay of treatment for background, breakthrough, procedural, and postoperative pain after burns. However, in addition to an impetus to reduce provider-driven opioid exposure, there is increasing evidence that opioids can worsen acute pain through induction of hyperalgesia. In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes. We hypothesized that these protocols would reduce inpatient opioid exposure without increasing acute pain scores. Methods Two groups of consecutive patients admitted to the burn service were compared: Pre (01/2018 to 07/2019) and Post (01/2020 to 06/2020) implementation of the protocols (08/2019 to 12/2019). Patient demographics, burn characteristics, and lengths of stay were abstracted from the burn registry. Opioid exposure and pain scale scores were obtained from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain specific MME, pain scores, and lengths of stay. Pain was estimated by creating a normalized pain score (range 0–1) from three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effect was estimated using Bayesian generalized linear models. Results There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174), including TBSA burn (Pre 4% [2, 10] versus Post 5% [2, 10], p=0.898). The Post group had significantly lower total MME (IRR 0.72, 95% CrI 0.57–0.93, posterior probability 99%), MME/day (IRR 0.76, 95% CrI 0.65–0.90, posterior probability 99%), and domain-specific total MME (Table). No difference in average normalized pain scores was seen. The Pre group were hospitalized longer than the Post group (5 days [2, 14] versus 4 days [1, 9], p=0.012). Conclusions Implementation of opioid-minimizing protocols for acute burn pain were associated with a significant reduction in inpatient opioid exposure without increased pain scores. More information is needed to understand the association with reduced hospital days.