Recommendations for Prescribing Opioids for People With Traumatic Brain Injury

Trexler, Lance E.; Corrigan, John; Dave, Shashank J.; Hammond, Flora M.

doi:10.1016/j.apmr.2020.07.005

Cited by 6 publications

(15 citation statements)

References 62 publications

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“…As shown in Table 2 : Study Characteristics, Description of Strategies and Outcomes, most guidelines came from the U.S. ( n = 13) [ 47 , 48 , 115 , 118 – 123 , 126 , 128 , 130 , 131 ]. They provided recommendations to prevent chronic opioid use in the following populations: surgery in general (20%) [ 48 , 116 , 117 , 123 ], orthopaedic surgery (35%) [ 118 , 124 , 125 , 127 , 128 , 130 , 132 ], trauma (25%) [ 47 , 122 , 126 , 129 , 131 ], a combination of trauma and orthopaedic surgery (10%) [ 119 , 120 ] as well as general and orthopaedic surgery (5%) [ 115 ], or patients with acute pain (5%) [ 121 ]. Guideline recommendations were classified according to the following categories: system-based, pharmacological, educational and multimodal.…”

Section: Resultsmentioning

confidence: 99%

“… Strongly recommended Trexler, 2020, USA [ 131 ] TBI Expert consensus U.S. Department of Health ad Human Services (Task Force), 2019, USA [ 121 ] All patients Complex opioid and non-opioid management should be reimbursed with the time and resources required for patient education; safe evaluation; risk assessment; re-evaluation; and integration of alternative and non-opioid modalities. Expert consensus Pharmacological - Opioid Prescription Practices Wainwright (ERAS Society), 2020, UK [ 132 ] TJA Add opioids only in the setting of suboptimal analgesia after first-line administration of nonopioid options or when the benefits outweigh the risks Strongly recommend, High level of evidence Edwards (ASER, POQI), 2019, USA [ 117 ] Patients on preoperative opioids Recommended (GRADE) Anger (PROSPECT), 2021, USA [ 127 ] TJA Expert consensus Trexler, 2020, USA [ 131 ] TBI, Franz (DMGP), 2019 Germany [ 129 ] SCI U.S. Department of Health ad Human Services (Task Force), 2019, USA [ 121 ] All patients No level of evidence The committee on trauma of the ACS, 2020, USA [ 126 ] Trauma Hsu, 2019, USA [ 46 ] Trauma The prescriber should use the lowest opioid effective dose for the shortest time period possible. Strongly recommended, high-quality evidence Edwards (ASER, POQI), 2019, USA [ 117 ] Patients on preoperative opioids Recommended (GRADE) Trexler, 2020, USA [ 131 ] TBI Expert consensus U.S. Department of Health ad Human Services (Task Force), 2019, USA [ 121 ] All patients Soffin, 2017, USA [ 118 ] …”

Section: Resultsmentioning

confidence: 99%

“… Expert consensus Pharmacological - Opioid Prescription Practices Wainwright (ERAS Society), 2020, UK [ 132 ] TJA Add opioids only in the setting of suboptimal analgesia after first-line administration of nonopioid options or when the benefits outweigh the risks Strongly recommend, High level of evidence Edwards (ASER, POQI), 2019, USA [ 117 ] Patients on preoperative opioids Recommended (GRADE) Anger (PROSPECT), 2021, USA [ 127 ] TJA Expert consensus Trexler, 2020, USA [ 131 ] TBI, Franz (DMGP), 2019 Germany [ 129 ] SCI U.S. Department of Health ad Human Services (Task Force), 2019, USA [ 121 ] All patients No level of evidence The committee on trauma of the ACS, 2020, USA [ 126 ] Trauma Hsu, 2019, USA [ 46 ] Trauma The prescriber should use the lowest opioid effective dose for the shortest time period possible. Strongly recommended, high-quality evidence Edwards (ASER, POQI), 2019, USA [ 117 ] Patients on preoperative opioids Recommended (GRADE) Trexler, 2020, USA [ 131 ] TBI Expert consensus U.S. Department of Health ad Human Services (Task Force), 2019, USA [ 121 ] All patients Soffin, 2017, USA [ 118 ] Orthopedic surgery Washington State AMDG, 2015, USA [ 120 ] All patients Edwards (ASER, POQI), 2019, USA [ 117 ] Patients on preoperative opioids The prescriber should avoid opioid dose escalation. Recommended (GRADE) Washington State AMDG, 2015, USA [ 120 ] …”

Section: Resultsmentioning

confidence: 99%

“… Strongly recommended, low-level evidence Hsu, 2019, USA [ 46 ] Trauma Avoid long-acting opioids in the acute phase. Strongly recommended, moderate-quality evidence Trexler, 2020, USA [ 131 ] TBI Expert consensus Hsu, 2019, USA [ 46 ] Trauma Benzodiazepines should not be prescribed in conjunction with opioids because of the significant risks posed by inconsistent sedation and the potential for misuse. Strongly recommended, high-quality evidence Trexler, 2020, USA [ 131 ] TBI Expert consensus Clarke, 2020, Canada [ 116 ] Surgery Patients should receive a prescription based on their opioid consumption in the hospital during the previous 24 hrs that should be written during the discharge process.…”

Section: Resultsmentioning

confidence: 99%

“… Strongly recommended, moderate-quality evidence Trexler, 2020, USA [ 131 ] TBI Expert consensus Hsu, 2019, USA [ 46 ] Trauma Benzodiazepines should not be prescribed in conjunction with opioids because of the significant risks posed by inconsistent sedation and the potential for misuse. Strongly recommended, high-quality evidence Trexler, 2020, USA [ 131 ] TBI Expert consensus Clarke, 2020, Canada [ 116 ] Surgery Patients should receive a prescription based on their opioid consumption in the hospital during the previous 24 hrs that should be written during the discharge process. Expert consensus The committee on trauma of the ACS, 2020, USA [ 126 ] Trauma No level of evidence The committee on trauma of the ACS, 2020, USA [ 126 ] Trauma Discharge prescriptions should separate opioids and nonopioid analgesics to make opioid tapering easier.…”

Section: Resultsmentioning

confidence: 99%

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Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Côté

Bérubé

Moore

et al. 2022

BMC Musculoskelet Disord

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Background Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area. Methods This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines. Results A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence. Conclusions This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

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