May 08, 2021
While pain control is a fundamental aspect of trauma care, opioid misuse over the past decade has prompted a shift in implementation. Today, rather than immediately turning to opioid therapy, Mayo Clinic Trauma Centers' leadership calls for an approach using multimodal pain management.
"This means using medications from different drug classes to control pain effectively in order to use fewer or no opioids," says Kevin B. Wise, M.D., a trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota, and associate medical director of the Adult Level I Trauma Center. "The reason I'm so passionate about it is because of the opioid crisis. One hundred thirty-five people a day die from opioids — more people per day than from car crashes."
He points out that if physicians dismiss 100 people on a hospital service with opioids, the following results will occur, according to the Centers for Disease Control and Prevention:
- One will become a heroin addict.
- One will die of opioid misuse.
- One will engage in opioid diversion.
Considering these statistics, Dr. Wise maintains proper opioid stewardship is critical.
While multimodal pain management isn't novel, the trauma field has adopted it more recently compared with other medical and surgical specialties, says Dr. Wise. "It's new to us here in trauma," he says. "Previously, most pain management focused almost solely on opioids. Trauma professionals used only a little multimodal pain control, such as using acetaminophen along with opioids. Now, we're using many pain medications."
Revising pain management in trauma care: A new pain control pyramid
Dr. Wise outlines the goal for patients' pain is to get it under control in the hospital. He sees a place for use of acetaminophen, naproxen, tramadol and lidocaine patches, using minimal amounts of oxycodone only for breakthrough pain after administering other medications. Use of a variety of these non-opioids can address different pain mechanisms and have a synergistic effect in combination, according to a 2017 article in the American Journal of Nursing.
Regional anesthesia techniques such as muscle and nerve blocks also serve an important role in multimodal pain management. Dr. Wise explains that data show non-opioid modalities can be just as effective in pain control, as noted in a 2019 article in Journal of the American College of Surgeons, which found multimodal pain management allowed less opioid usage for trauma patients while they reported pain scores equivalent to opioid therapy.
Timing is crucial for managing pain successfully using a combination of non-opioid pain therapies, however. "If you start upfront with managing a patient's pain multimodally the moment you get on the trauma service, you can rapidly de-escalate the pain," says Dr. Wise. "If you wait too long and get into a pain crisis, it's extremely hard to bring it down."
He notes that trauma professionals may be nervous about vigorous pain control efforts upfront because of concerns about side effects. Yet this can backfire. "If you are not aggressive upfront, though, the horse gets out of the barn, and it's hard to play catch-up," he says.
In this pain management model, even though a patient who has grievous injuries still may require some oxycodone, the amount needed for effective pain control is significantly reduced.
The pain control pyramid now looks different from in the past. Whereas oxycodone used to be the bedrock of trauma pain control, now non-opioids are fundamental. "The foundation of the house is now all the other drugs," Dr. Wise says. "Oxycodone is now the last thing you add."
Dr. Wise emphasizes using oral versus intravenous medication for pain control, as it offers longer duration of action and ability to taper off gradually. Though the onset of action with pills is slower, he points out that it wears off more slowly.
Elements for successful trauma multimodal pain management
Dr. Wise explains the following shifts are crucial for the trauma field to implement multimodal pain management effectively:
Awareness
Physicians and nurses must be aware of the opioid crisis and non-opioid alternatives, says Dr. Wise. He believes understanding the opioid problem's magnitude and the effectiveness of other pain management strategies will motivate trauma professionals to change their pain control practices.
Patient and family education
Multimodal pain management is a culture change not only for medical professionals but also for patients and their families, especially when they've had experience with pain control via opioids.
"A lot of patients have been in the hospital before, and oxycodone is what they're used to," says Dr. Wise. "I find if I talk to patients about the way we are approaching their pain control, however, they will understand and agree. When actually implemented and pain medications are given as prescribed, patients are really pleased with the pain control."
Where the opioid epidemic stands today
The trigger for this change in pain management, the opioid epidemic, has gotten far worse since 2017, according to Dr. Wise, but it's now starting to level off. He notes that yearslong work on this problem is now bearing some fruit. "It's still very, very bad, however," says Dr. Wise. "Opioid deaths are still rising, but just not as fast as before. We haven't quite turned the ship around. The death toll is still a plane full of people crashing daily."
Those whose deaths are related to opioid use include both prescription users and those who divert the drugs to others. "What happens is Grandma takes home 50 oxycodone from the hospital and doesn't need them all," says Dr. Wise. "Maybe they're stolen by someone doing work in her house, or perhaps family members either sell them or use them recreationally. That's why many people become addicted to heroin — an illicit opioid — because eventually the oxycodone supply runs out and heroin can still be found."
Where to go from here: Current and future pain control practices
Nonaddictive opioid alternatives central to a multimodal pain management strategy are inexpensive, widely available and generally well tolerated. Trauma professionals should start using them with their patients today, if they aren't already, says Dr. Wise.
"The part of opioids that's problematic is the part that produces euphoria. It produces dependency, and with the way our brain chemistry works, it's kind of like trying to eat just one potato chip," he says. "Multimodal pain management is the answer until we get new drugs to provide analgesia without the euphoria."
For more information
Drug overdose deaths. Centers for Disease Control and Prevention.
Palomano RC, et al. Multimodal analgesia for acute postoperative and trauma-related pain. American Journal of Nursing. 2017;117:S12.
Hamrick KL, et al. Multimodal analgesia and opioid use in critically ill trauma patients. Journal of the American College of Surgeons. 2019;228:769.