Multimodal Pain Control Strategy Shows Promise in Trauma Patients

By Jonathan Springston, Editor, Relias Media

Patients who sustained a traumatic injury or underwent a serious procedure maintained low pain scores and avoided heavy opioid exposure through a multimodal regimen that included drugs that can alleviate pain but are not overly strong or habit-forming.

At a trauma center in Houston, investigators proposed using two multimodal pain regimen (MMPR) strategies to help patients manage pain and recover well. The primary outcome was oral morphine milligram equivalents (MME) per day. The secondary outcomes included total MME during hospitalization, pain scores, and opioid prescribing at discharge.

Clinicians developed the MMPR concept in 2013. It calls for intravenous and oral acetaminophen, 48 hours of celecoxib and pregabalin, naproxen and gabapentin, scheduled tramadol, and as-needed oxycodone. Since then, clinicians have noted this combination includes drugs that can be expensive, are not widely available, and may not be covered by insurance. Further, tramadol is considered a narcotic-like drug.

Thus, investigators tried another combination called MAST MMPR, which includes oral acetaminophen, naproxen, gabapentin, lidocaine patches, and as-needed opioids. Researchers randomized 787 patients to the original MMPR and 774 patients to the MAST MMPR. These patients had sustained rib fractures, a traumatic brain injury, or long bone fractures. Others had undergone procedures such as laparotomy, thoracotomy, or limb amputation.

Those on the MAST MMPR solution were exposed to fewer opioids overall. However, reported pain scores were identical between the two groups (3.3 on the Numeric Rating Scale for pain). Still, the authors demonstrated that alternative pain control techniques exist and can be effective.

“We used a generic pain regimen that is affordable at discharge. The discharge medications acetaminophen and naproxen can be bought over the counter. The only drug that requires a prescription is gabapentin and an as-needed opioid, if prescribed,” John A. Harvin, MD, FACS, an associate professor for the department of surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth) and trauma surgeon at the Red Duke Trauma Institute at Memorial Hermann-Texas Medical Center, said in a statement. “The MAST MMPR is a regimen that can be duplicated in any trauma center. However, first, the culture of an institution needs to change. Implementation requires education, auditing feedback about responsible opioid prescribing, physician and nursing champions to lead efforts to change clinical practice, and managing the expectations of how to treat pain with other, non-opioid adjuncts.”

Speaking of alternatives to opioids, the National Center for Complementary and Integrative Health, a division of the National Institutes of Health, is funding a multicenter study of the feasibility of offering acupuncture to patients who present to the ED complaining of pain and/or anxiety, as reported in the February issue of ED Management.

For even more relevant resources, check out the Rounds With Relias podcast series Episode 2, Opioid Diversion — Reducing Risks in Your Facility, and Episode 12, Provider Burnout When Treating Opioid Use Disorder.