Establishing Geriatric Opiate Use Patterns in Trauma

Introduction

The opioid crisis is an ongoing issue in the United States and is related to high morbidity, mortality, and economic costs. ¹ There is evidence that providers often overprescribe opiates in the postoperative period, increasing likelihood of opiate dependence and addiction ² ; however, there is little research detailing current opiate usage in older patients after trauma. The geriatric population presents a variety of unique challenges for pain management and prescription drug dependence due to sensitivity, a narrow therapeutic window, and high rates of pre-existing polypharmacy. It is well-established that opioid medications put geriatric patients at risk for delirium. ³ Additionally, a 2018 study found that opiate prescriptions in the geriatric population are associated with increased incidence of ground level fall. ⁴

A trial performed by Young et al found that although geriatric patients were less frequently prescribed opioids at discharge following trauma hospitalization compared to the non-geriatric population, they received a higher dosage of opioids when prescribed. ⁵ This type of variability in practice patterns may lead to harm in this vulnerable patient population. Morphine milligram equivalents (MME) is a well-established tool that can standardize narcotic dosages across medications by considering medication strength per unit, number of units given per day, and morphine equivalent conversion factor. ⁶ The objective of this study is to assess the use of narcotics in geriatric trauma patients with various injury patterns, using MME, to establish a reference point for future intervention in narcotic reduction.

Methods

This study was approved by the Institutional Review Board at Augusta University. Charts for trauma patients equal to or over the age of 65 admitted to a single level 1 trauma center in the Southeastern United States were reviewed. The information gathered comprised of patient factors (including age, sex, past medical history, and documentation of opiate naivety/previous narcotic use), injury patterns, operative intervention, pain medications prescribed during hospitalization and at time of discharge, total and average daily MME inpatient and outpatient, and requests/prescriptions for narcotics at outpatient follow-up. The timeframe for data collection was January 1, 2019 through December 31, 2019. Information was pulled from the institutional trauma database and supplementary chart review was performed. MME was calculated using the conversion factors of common oral, transdermal, and intravenous opioids. The medication administration record was reviewed for all inpatient narcotics given orally, intravenously, and through continuous infusions. The total amount of prescribed narcotics at time of discharge and follow-up was considered for outpatient MME. At our institution, every trauma patient who is admitted is given multimodal therapy, which includes Tylenol, gabapentin, Robaxin, and opioids, per departmental policy that was instated prior to the year of this study.

Results

In 2019, there were 475 patients equal to or over the age of 65 admitted to our level 1 trauma center for acute traumatic injuries. Ages ranged from 65 to 101, with a mean 77.5 years. This geriatric patient cohort was 51.4% female. Upon review of past medical records, 104 patients (21.9%) were documented to have been previously prescribed an opioid. Using an unpaired t test, we compared 371 patients with no documented previous exposure and 104 patients with previous documented exposure, and found a mean of 165.88 in the opiate naïve group and 179.56 in the exposed group (P = .75).

Among this cohort of geriatric patients requiring trauma admission, 97.7% involved blunt trauma and 2.3% involved penetrating trauma. There were 93 (19.6%) patients with rib fracture(s), 22 (4.6%) patients with pelvic fracture(s), 104 (21.9%) patients with intracranial bleed(s), 189 (39.9%) patients with long bone fracture(s), 71 (14.9%) with spinal fracture(s), and 29 (6.1%) patients with face/skull fracture(s). A total of 219 (46.2%) patients required operative intervention. Average total inpatient MME was 169.0 with a large standard deviation of 392. Average daily MME was 22.89 with a standard deviation of 26.9. The mean length of stay was 7.63 days, with a mode of 2 days, and range of 1-117 days. The average total prescribed MME upon discharge was 79.27 with a standard deviation of 118.61 (Figure 1).

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Figure 1.

MME for geriatric trauma patients admitted in 2019.

There were 79 total patients who had a hospital MME of 0. The age range of these patients was 65-99. Of these patients, 14 had advanced injuries and 38 had intracranial hemorrhages. The average length of stay was 4.56.

After discharge, 61.2% of patients returned for a follow-up clinic appointment. Overall, 20% of patients attended at least one appointment with an orthopedic service, 8% attended at least one appointment with the general surgery trauma service, and 6% attended at least one appointment with a neurosurgical service. There were 29 patients (10%) documented to request a narcotic prescription refill at time of clinic follow-up. Of the 27 narcotic prescriptions written or renewed at outpatient clinics, 57% came from orthopedic clinics, 17% from the general surgery trauma clinics, 17% from neurosurgical clinics, and 10% from plastic surgery clinics. Tramadol and oxycodone were the most frequently prescribed outpatient narcotic medications, prescribed with equal frequency.

Discussion

It is well-established that the ongoing opioid epidemic in the United States has complicated treating acute pain after trauma. Special attention must be paid to opioid tolerance in this context to mitigate adverse physiologic effects, inadequate analgesia, and symptoms of withdrawal. ⁷ Managing pain after a trauma can be very difficult and impacted by many factors such as metabolism, body composition and size, tolerance, and comorbidities. The geriatric population is at substantially increased risk of adverse pharmacologic effects of opioids such as nausea, constipation, urinary retention, sedation, cognitive impairment, pruritis, and respiratory depression due to higher incidence of comorbidities and polypharmacy. ⁸ Given the increased risk for adverse effects in the geriatric population, the use of narcotic medications to treat pain in this population should be addressed with caution. Additionally, different opioid medications have variable potency and time of effectiveness and clinicians have diverse preferences for how to treat pain. Morphine milligram equivalents can be used to appropriately quantify how much opioids a patient is receiving, especially when a patient has been receiving multiple different narcotic medications of various potencies via multiple routes while hospitalized. Standardization of prescribing practices into MME can help clinicians gain a greater understanding of current pain management strategies and facilitate the establishment of safe practices moving forward.

This study shows that at our institution there is large variability in the quantity of opioids used for pain management in trauma patients age 65 years or greater with total inpatient MME ranging from 0 to 6792, average daily MME ranging 0 to 307.5, and total prescribed MME at discharge ranging 0 to 900. Some of this variability may be attributed to severity of injuries, whether operative management was required, and length of stay. We considered using injury severity score (ISS) to stratify our dataset; however, we determined that it would be difficult to attribute a set baseline of opioid treatment for any numerical ISS as patients will ultimately tolerate, feel, and describe pain in different manners. Injury type proved to be a difficult measure to use as an independent factor given the homogeneity of the mechanism in this age group. The vast majority were ground level falls, but we could not find any correlation between specific injury type and MME use. In the 65 and older population, there were only 10 penetrating mechanisms, with this number so low, we also could not find significant difference in blunt and penetrating MME use.

Although it may be assumed that patients who have previously been exposed to opioid medications in the past may be sensitized and therefore require higher doses, we did not find a significant difference between these two groups. Risk for opioid dependence cannot be directly extrapolated from this data; however, attention to current opioid prescribing practices can help bring light to potential overprescribing of narcotics in this vulnerable population.

There are many limitations to this study. This was a retrospective study dependent on reviewing the electronic health record. We initially chose pain scores as a measure for abstraction; however, we found that there was too much variability in patient responses especially with the inclusion of patients requiring ICU care and/or intubation who required a different pain scoring system. We decided to not include pain scores as we were not able to standardize them in a meaningful manner and are limited by the retrospective nature of this study. From reviewing charts, it was rarely noted if patients were opioid naïve. Clinic notes tend to lack detail about patients reports of pain, their current narcotic use, if any, and whether a discussion regarding expectations was had. Additionally, it would be beneficial for future studies to further stratify this database to separate patients requiring intensive care unit stays from floor patients as the use of continuous infusions can skew the data for average patients receiving opioids for analgesia. Finally, due to stigma, patients are unlikely to admit to a current opioid addiction, so this is certainly an unreliable way to gauge if patients may already struggle with opioid addiction. Patient surveys and inclusion of pain scores may be useful in the setting of future prospective studies where more standardization may be possible from the onset and to better establish past opioid use and daily need for narcotic pain control while hospitalized.

Provided appropriate pain management in the setting of trauma is a complex issue and the reduction of opioid use likely requires a multidisciplinary approach. The use of multimodal pain regimens has been shown to reduce the use of opioid medications in trauma patients ⁹ and should be used in the geriatric population after careful consideration of comorbidities and potential side effects. Although currently not well characterized, cognitive behavior therapy (CBT) may have some effect on pain control ¹⁰ and would be an interesting intervention to study in the realm of acute trauma. Increased provider and patient education on the elevated risks of opioid medications in the geriatric population may also benefit in the partnership between patients and providers to control pain while minimizing dependence on narcotics.

Conclusion

Despite the well-established challenges of treating acute traumatic pain and the increased risks related to pain management in the geriatric population, there is a paucity of research investigating opioid use for geriatric patients in the traumatic setting. This study helps to establish an appreciation of opioid prescribing practices at our institution for this vulnerable population as well as provide increased cognizance of MME calculation, hopefully which might alter prescribing habits of providers.

It is imperative for physicians to have more conscientious opioid prescribing practices to avoid over prescribing while also appropriately managing pain. Special attention to the severity of traumatic injuries and sensitization to opioids throughout hospitalization may help clinicians hone opioid prescribing practices. This dataset establishes a reference point for opiate use in geriatric trauma patients to help facilitate further research for mitigation of risk in this population. As the geriatric population continues to grow in the United States, it is of the utmost importance to advance this research, ensuring appropriate pain management strategies in the setting of acute traumatic injuries to provide adequate analgesia, but still ultimately do no harm.