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Harvin JA, Albarado R, Truong VTT, et al. Multi-Modal Analgesic Strategy for Trauma: A Pragmatic Randomized Clinical Trial. J Am Coll Surg. 2021 Mar;232(3):241-251.e3. doi: 10.1016/j.jamcollsurg.2020.12.014. Epub 2021 Jan 21. (Original study)
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.

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Physician rater

The clinical significance of these results is rather unclear. Aside from a slightly simpler protocol in the "MAST" group, in which IV administration was avoided, the only substantive difference in regimen appears to have been elimination of Tramadol from the original mix. Since the study was unblinded and the rationale was therefore open, it would seem that the decrease in opioid prescription rate that resulted could easily have been biased. It also resulted in decreased pain control, at least for some patients.

Physician rater

The routine use of gabapentin raises new questions; however, what is the cost of the reduction in opioid use?

Physician rater

This is an interesting trial that suggests a benefit in reducing morphine use on those on a multimodal analgesic program while admitted to hospital. While it may encourage those working in the ED to use adjuctive non-opioid therapy where possible, more evidence is needed for what works (or doesn't) in the ED for pain control in trauma patients.

Physician rater

This is a highly relevant article that most physicians must be made aware of.

Physician rater

This information is very useful for every physician working with trauma patients.

Physician rater

An interesting study. As a Trauma Surgeon, I would have expected these results. The benefit to me is that it provides further evidence as well as additional questions regarding optimal provision of care now for acute pain due to trauma while encouraging continued investigations to further reduce opioid use in our patient population.
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