Background & Aims
Pain is a major source of disability after a neurotrauma, namely traumatic brain injury (TBI) and spinal cord injury (SCI).(1) Post-traumatic headaches affect almost half of TBI patients shortly after the injury, while prevalence can reach 70% several months later.(2) Similarly, the majority of SCI patients are likely to suffer from nociceptive pain following spinal surgery and more than half will develop neuropathic pain within days of injury.(3) In addition, the prevalence of chronic pain in patients with SCI varies from 30% to 95%, depending on the characteristics of the injury.(4) Opioids have been one of the preferred analgesics for managing pain in trauma patients.(5,6) Nevertheless, data on the use of these analgesics and their adverse effects (AEs) in neurotrauma are however still limited. Thus, the aims of this study were to describe the use of opioids and other pain management approaches in TBI and SCI patients, and to examine the AEs of opioids in these populations.
Methods
This prospective descriptive study was conducted in a Level I trauma centre in Canada from December 2020 to July 2022. We consequently recruited admitted adult patients (? 18 years old) with mild, moderate, or severe TBI(7) and patients with ASIA A to D SCI.(8) We excluded patients who had undergone surgery for indications other than TBI and SCI. We collected data on pain intensity with the Brief Pain Inventory (BPI)(9), on neuropathic pain with the Neuropathic Pain Symptoms Inventory(10), on opioid use in oral morphine equivalent dose per day (MEDD)(11), on non-pharmacological strategies with the Non-Pharmacological Pain Management Strategies questionnaire(12) and on opioids AEs with the Opioid Adverse Effects questionnaire (12-14) at hospital discharge (T1) and at 3 months post-injury (T2). We also collected data on pain interference with activities with the BPI8 and opioid misuse using the Opioid Compliance Checklist at T2.(15) Descriptive statistics were calculated.
Results
A total of 70 (73%) of the 96 approached patients agreed to participate, 70% of them with TBI and 30% with SCI. Their mean age was similar (57 ±21 vs. 56±18). Mean average pain intensity at T1 and T2 was mild in both populations, while mean neuropathic pain was low in TBI and moderate in SCI patients. Mean pain interference with activities was low at T2. At T1, 80% of participants were using opioids, whereas at T2, 26% of TBI and 53% of SCI patients used them. The mean MEDD was close to 10 mg in TBI and SCI patients at T1 and T2. The main coanalgesics used were acetaminophen and gabapentinoids at T1 and T2 in TBI (71% and 17%; 36% and 14%) and SCI patients (81% and 40%; 93% and 40%). Non-pharmacological strategies were used by less than 30% of participants. The main AEs at TI and T2 were drowsiness and constipation for TBI (43% and 32%; 20% and 45%) and for SCI patients (50% and 40%; 33% and 34%). Nearly 10% of TBI patients misused opioids at T2.
Conclusions
This study showed that the pain in neurotrauma patients was well controlled and that most were using opioids at the time of discharge from the trauma centre, with a significant proportion still using these analgesics three months post-injury. The average MEDD remained relatively stable during the transition period from acute to chronic pain and within the recognized safe zone for avoiding intoxication in TBI and SCI patients. However, many participants reported drowsiness and constipation, AEs that could be explained by the neurotrauma itself, but could also be exacerbated by opioid use and thus compromise the ability to engage in rehabilitation activities. Opioid misuse was not identified in a large proportion of participants, but a greater tendency to misuse was identified in TBI patients, which remains to be confirmed. An intervention to support patients in the optimal use of opioids in the early months following neurotrauma is needed.
References
1-Potential Lost, Potential for Change: The Cost of Injury in Canada. Available from: https://parachute.ca/en/professional-resource/cost-of-injury-in-canada/.
2-Khoury S, Benavides R. (2018). Pain with traumatic brain injury and psychological disorders. Prog Neuropsychopharmacol Biol Psychiatry, 87, 224-233.
3-Bryce, T. N., Biering-Sorensen, F., Finnerup, N. B., Cardenas, D. D., Defrin, R., Lundeberg, T. & al. (2012). International spinal cord injury pain classification: part I. Background and description. Spinal Cord, 50, 413-417.
4-Dijkers, M., Bryce, T. & Zanca, J. (2009). Prevalence of chronic pain after traumatic spinal cord injury: a systematic review. J Rehabil Res Dev, 46, 13-29.
5-Johnston JP, LaPietra AM, Elsawy OA, Wang A, Richards LM, Yee S, et al. (2023). Opioid Prescribing at Discharge in Opioid-Naïve Trauma Patients. Am Surg, 89, 113-9.
6-El Moheb M, Herrera-Escobar JP, Maurer LR, Langeveld KMC, Kapoen C, Heyman A, et al. (2022). The variation of opioid prescription after injury and its association with long-term chronic pain: A multicenter cohort study. Surgery, 172, 1844-50.
7-Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT (2008). Classification of traumatic brain injury for targeted therapies. J Neurotrauma, 25, 719–738.
8-American Spinal Injury Association (2019). International Standards for Neurological Classification of Spinal Cord Injury. ASIA: Richmond, USA.
9-Cleeland C. The brief pain inventory user guide; 2009. Available from: https://www.mdanderson.org/documents/Departments-and-Divisions
/Symptom-Research/BPI_UserGuide.pdf.
10-Bouhassira D, Attal N, Fermanian J, et al. (2004). Development and validation of the Neuropathic Pain Symptom Inventory. Pain, 108, 248–257.
11-Svendsen K, Borchgrevink P, Fredheim O, Hamunen K, Mellbye A, Dale O. (2011) Choosing the unit of measurement counts: the use of oral morphine equivalents in studies of opioid consumption is a useful addition to defined daily doses. Palliat Med, 25, 725-32.
12-Choiniere M, Ware MA, Page MG, et al. (2017) Development and implementation of a registry of patients attending multidisciplinary pain treatment clinics: the Quebec pain registry. Pain Res Manag: 8123812.
13-Moulin DE, Clark AJ, Gordon A, et al. (2015). Long-term outcome of the management of chronic neuropathic pain: a prospective observational study. J Pain, 16, 852–861.
14-Apfelbaum JL, Gan TJ, Zhao S, Hanna DB, Chen C. (2004). Reliability and validity of the perioperative opioid-related symptom distress scale. Anesth Analg, 99, 699–709.
15-Jamison RN, Martel MO, Edwards RR, Qian J, Sheehan KA, Ross EL. (2014) Validation of a brief opioid compliance checklist for patients with chronic pain. J Pain, 15, 1092–1101.
Presenting Author
Melanie Berube
Poster Authors
Mélanie Bérubé, NP, PhD
PhD
Université Laval
Lead Author
Marie-Ève McGennis
RN
Université Laval
Lead Author
Caroline Côté
Université Laval
Lead Author
Jerôme Paquet
MD
CHU de Québec - Université Laval
Lead Author
Michael Verret
MD
University of Ottawa
Lead Author
Marc O Martel
PhD
McGill University
Lead Author
Line Guénette
D.Pharm
Université Laval
Lead Author
Cécile Duval
D.Pharm
Université Laval
Lead Author
Valerie Turcotte
NP
Université Laval
Lead Author
Claude-Édouard Chatillon
MD
Université de Montréal
Lead Author
Andréane Richard-Denis
MD
Université de Montréal
Lead Author
Léonie Archambault
PhD (cand.)
McGill University
Lead Author
Marc-Aurèle Gagnon
M.Sc
Université Laval
Lead Author
Alexis Turgeon
MD
Université Laval
Lead Author
Topics
- Treatment/Management: Pharmacology: Opioid