Event 2: Trauma and Treatment

4 Months Later

  • Alison continued to see her primary care physician (PCP), counselor and recovery coach.
  • Unfortunately 4 months after she transitioned her medications to her PCP, she was in a Motor Vehicle Accident and sustained multiple left-sided rib fractures as well as a jaw fracture.
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Ms. Tatum reclines on a hospital bed wearing a hospital gown and neck brace.
Ms. Tatum in the Emergency Department

Trauma Review

  • Alison takes Buprenoprhine/naloxone 8mg/2mg two times a day.  Her last dose of 8mg/2mg was this morning.
  • She will need an oral surgical procedure to manage her jaw injury.
  • She has a pending consult from the maxillofacial surgery, trauma surgery, and addiction services to assist in treatment planning. 
  • She has severe pain in the face, neck, and ribs and needs an acute pain management plan.
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Ms. Tatum lays on a hospital bed and talks to a medical worker standing beside her.
Ms. Tatum speaks to an Emergency Department doctor

Acute Pain Management For Ms. Tatum

Alison will require surgery.  What do you plan to do with her buprenorphine/naloxone (select the appropriate answer(s))?

Correct
Correct
Correct
Correct
Correct

Emergency Department Meeting with Addiction Specialist

Ms. Tatum’s Acute Pain and Buprenorphine

  • There are conflicting protocols regarding buprenorphine/naloxone dosing or cessation and acute pain management – no conclusive data supports favoring one strategy over another.1-5 
  • For elective surgery, some recommend to stop or decrease the dose of buprenorphine/naloxone a few days prior to surgery and others recommend continuing the regular home dose. 
  • For acute pain and non-elective surgery, recommendations on buprenorphine treatment continue to be variable and if available, an acute pain service or addiction consult may be beneficial to guide treatment.
  • Decreasing or stopping the buprenorphine/naloxone, in addition to the acute, stressful situation, may put her at risk  or a set back or even fatal overdose.6
  • Buprenorphine may provide significant pain relief and can be divided into BID or TID dosing to improve pain relief.
  • If additional other opioid pain medications are needed in patients with OUD treated with buprenorphine/naloxone, generally speaking they may require higher doses of opioid, regardless of decreasing or stopping the home medication dose. 
  • Surgical/peri-operative opioid management strategies can be discussed and agreed upon by her team.
  • Maximizing non-opioid management strategies should be prioritized.7

References

  1. Ward EN, Quaye, AN, Wilens TE.  Opioid Use Disorders:  Perioperative Management of a Special Population. Anesth Analg 2018; 127(2):539-547.
  2. Alford D, Compton P, Samet J. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2007;48:127–134.
  3. Stern E. Buprenorphine and the Anesthesia Considerations: A Literature Review. Nurse Anesthesia Capstones. 2015.
  4. The perioperative management of patients maintained on medications used to manage opioid addiction. Curr Opin Anaesthesiol. 2014;27:359–364.
  5. Jonan AB, Kaye AD, Urman RD. Buprenorphine Formulations: Clinical Best Practice Strategies Recommendations for Perioperative Management of Patients Undergoing Surgical or Interventional Pain Procedures. Pain Physician. 2018 Jan;21(1):E1-E12.
  6. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017; 357:j1550.

  7. Anderson TA, Quaye ANA, Ward EN, Wilens TE, Hilliard PE, Brummett CM. To stop or not, that is the question: acute pain management for the patient on chronic buprenorphine. Anesthesiology. 2017;126:1180–1186.

Opioid Summary for Ms. Tatum

  • The inpatient addiction and pain management teams recommend increasing buprenorphine/naloxone to 8mg TID post-operatively. 
  • They contact her PCP to make her aware of this change with the goal to decrease back to her home dose of 8mg BID at hospital discharge.
  • They will avoid IV fentanyl given her history of heroin/fentanyl addiction and use hydromorphone or morphine as needed if non-opioid adjuvants do not provide adequate relief.

Non-Opioid Medication Options for Ms. Tatum

Maximizing non-opioid medications can help to decrease her opioid pain control needs.1

Consider acetaminophen 1 gram by mouth or IV before surgery and TID or QID after surgery if no liver concerns

Consider giving an anti-inflammatory agent in discussion with the surgeon – though controversial, some believe NSAIDs impair bone healing2-5

Celecoxib (if able to take by mouth) or

IV ketorolac 30 mg up to TID

Caution with bleeding or gastrointestinal distress (and avoid in patients with renal insufficiency or significant dehydration)

If unable to take celecoxib, consider a corticosteroid

Pre-emptively reduces inflammation and nausea without risk of bleeding

Gabapentinoids

The benefit of gabapentinoids is unclear6

Gabapentin or pregabalin pre-operatively and post-operatively may lower pain

May be indicated if pain has neuropathic qualities (e.g. burning, shooting, stabbing)

May increase post-op sedation and respiratory suppression 

Perioperative dosing may vary based on patient characteristics and comorbidities

Ketamine

Ketamine may be useful as an adjunct to anesthesia and provide pain relief7

Anti-depressants

Anti-depressants may decrease the need for post-operative pain medications if  given during the peri-operative period8

References

  1. Kaye AD  et al.  An Update on Nonopioids: Intravenous or Oral Analgesics for Perioperative Pain Management. Anesthesiol Clin. 2017 Jun; 35(2):e55-e71.
  2. Su B, O’Connor JP. NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol (1985). 2013;115(6):892-899.

  3. Goodman SB, Ma T, Mitsunaga L, Miyanishi K, Genovese MC, Smith RL. Temporal effects of a COX-2-selective NSAID on  one ingrowth. J Biomed Mater Res A. 2005;72(3):279-287.104.

  4. Dodwell ER, Latorre JG, Parisini E, et al. NSAID exposure and risk of nonunion: A meta-analysis of case-control and cohort studies. Calcif Tissue Int. 2010;87(3):193-202.

  5. Jeffcoach DR, Sams VG, Lawson CM, et al. Nonsteroidal anti-inflammatory drugs’ impact on nonunion and infection rates in long-bone fractures. J Trauma Acute Care Surg. 2014;76(3):779-783

  6. Su B, O’Connor JP. NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol (1985). 2013;115(6):892-899.

  7. Goodman SB, Ma T, Mitsunaga L, Miyanishi K, Genovese MC, Smith RL. Temporal effects of a COX-2-selective NSAID on bone ingrowth. J Biomed Mater Res A. 2005;72(3):279-287.104.

  8. Dodwell ER, Latorre JG, Parisini E, et al. NSAID exposure and risk of nonunion: A meta-analysis of case-control and cohort studies. Calcif Tissue Int. 2010;87(3):193-202.

  9. Jeffcoach DR, Sams VG, Lawson CM, et al. Nonsteroidal anti-inflammatory drugs’ impact on nonunion and infection rates in long-bone fractures. J Trauma Acute Care Surg. 2014;76(3):779-783.

Interventional options for Ms. Tatum

In order to improve pain control, target her rib pain, and reduce the need for additional opioid medication, the teams opt to place a thoracic epidural (a continuous infusion of medication into the spine around the dura mater of the spinal cord to provide analgesia to the chest wall).

  • Rib fractures can be extremely painful.
  • Thoracic epidural catheters placed in the thoracic spine, administering a local anesthetic infusion to cover the area of pain, may provide significant relief of her rib fracture pain and reduce medication requirements, but outcomes are controversial.1-2
  • Paravertebral nerve blocks or intercostal nerve blocks are alternatives to epidural pain control
    • They may provide pain relief and reduced pulmonary complications
    • They have not been demonstrated to be superior to epidural analgesia
  • Start thoracic epidural local anesthetic, bupivacaine 0.25% at 8 mL/hour
  • Can increase rate up to 12 mL/hour if partial rib coverage and vital signs tolerate a dose titration
    • Collaboration with Anesthesia/Pain Service is vital for success
      • Discuss use of any anticoagulants or systemic opioids
      • Monitor pain relief and local anesthetic coverage
  • Paravertebral nerve blocks or intercostal nerve blocks are alternatives to an epidural
    • Provide relief & reduced pulmonary complication
    • Not superior to epidural analgesia

References

  1. McKendy KM, Lee LF, Boulva K, Deckelbaum DL, Mulder DS, Razek TS, Grushka JR. Epidural analgesia for traumatic rib fractures is associated with worse outcomes:  a matched analysis.  J Surg Res 2017; 214: 117-123.
  2. Jensen CD, Stark JT, Jacobson LL, Powers JM, Joseph MF, Kinsella-Shaw JM, Denegar CR. Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures. Pain Med 2017; 18(9): 1787-1794.

Non-Pharmacologic Pain Management Strategies for Her Acute Pain

Ms. Tatum will benefit from other non-medication options for pain control and improved coping.  These options may include:

  • Topical cooling/ice of injured parts of body
  • Adequate hydration and nutrition
  • Assistance in learning relaxation/calming techniques
  • Facilitate the use of methods that have helped in past as applicable
  • Teach breath-focused relaxation, body scanning and pleasant imagery

Distraction aligned with interests (may help to change the perception of pain)

  • Music, reading, computer-based activities, TV/videos
  • Adaptive thinking

Recognize and reframe cognitive distortions (catastrophizing)

  • Build confidence in self-management (self-efficacy)
  • Controlling strong emotions, stress reduction
  • Staying connected (family, friends, pets, spirituality, recovery support)
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