An observational study on risk factors for prolonged opioid prescription after severe trauma

Jenny Åström 1 , Ylva Lidén 2 , Rikard K. Wicksell 1 , Anders Wincent 2  and Karl-Fredrik Sjölund 2
  • 1 Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
  • 2 Pain Center, PMI, Karolinska University Hospital, Stockholm, Sweden
Jenny Åström, Ylva Lidén, Rikard K. Wicksell, Anders Wincent and Karl-Fredrik Sjölund

Abstract

Background and aims:

Trauma is one of the most common causes of morbidity and mortality in people of working age. Following surgery, approximately 10% of patients develop persistent postsurgical pain. Chronic pain is a complex phenomenon that can adversely affect quality of life and is associated with psychiatric conditions such as anxiety and depression. Pharmacological treatment is normally insufficient to fully alleviate chronic pain and improve functional capacity, especially in the long term. The appropriateness of opioid treatment in chronic non-cancer pain has become increasingly examined with high numbers of serious side effects including drug dependency and death. The present study was based on clinical observations suggesting that a problematic opioid use can be initiated during trauma care, which implies the importance of evaluating opioid therapy and its effect on trauma patients. Specific attention is given to patients with known psychiatric conditions which may render them more vulnerable to develop problematic opioid use. The aim of this observational study was to broadly characterize patients referred to a pain specialist after severe trauma regarding their trauma type, psychiatric co-morbidity, and opioid prescription pattern. This was done to tentatively investigate possible risk factors for long-term opioid use following trauma.

Methods:

Trauma patients referred to the Pain Center at Karolinska University Hospital, Sweden (n=29) were recruited for the study over a period of 2 years. Demographic information, trauma-related data as well as psychiatric diagnoses and pharmacological prescriptions were retrieved from the registry SweTrau and electronic medical records.

Results:

Among the 29 participants (age range 21–55 years, median=34; 76% male), 14 (48%) were prescribed opioids at least once during the 6-months period preceding the trauma. For 21 patients (72%) opioids were prescribed 6 months after the trauma. One year after the trauma, 18 patients (62%) still had prescriptions for opioids corresponding to daily use or more, and two other patients used opioids intermittently. Twenty patients (69%) had psychiatric diagnoses before the trauma. According to the medical records, 17 patients (59%) received pharmacological treatment for psychiatric conditions in the six months period preceding the trauma. During the follow-up period, psychiatric pharmacological treatment was prescribed for 27 (93%) of the patients.

Conclusion and implications:

For most of the participants opioids were still being prescribed one year after trauma. The majority presented with psychiatric co-morbidity before trauma and were also prescribed psychiatric medication. Findings support the notion that patients with a complex pain situation in the acute phase following trauma are at risk for prolonged opioid prescription. These results, although tentative, point at psychiatric co-morbidity, opioid use before trauma, high injury severity, extensive surgery and extended hospital stay as risk factors for prolonged opioid prescription after severe trauma. This study is purely observational, with a small sample and non-controlled design. However, these data further emphasize the need to identify patients at risk for developing problematic long-term opioid use following trauma and to ensure appropriate pain treatment.

  • [1]

    World Health Organization. Injuries and violence: the facts 2014. Accessed May 14, 2019. Available from: http://www.who.int.

  • [2]

    Rivara FP, MacKenzie EJ, Jurkovich GJ, Nathens AB, Wang J, Scharfstein DO. Prevalence of pain in patients 1 year after major trauma. Arch Surg 2008;143:282–7.

    • Crossref
    • PubMed
    • Export Citation
  • [3]

    Todd KH, Ducharme J, Choiniere M, Crandall CS, Fosnocht DE, Homel P, Tanabe P, PEMI Study Group. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain 2007;8:460–6.

    • Crossref
    • PubMed
    • Export Citation
  • [4]

    Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367:1618–25.

    • Crossref
    • PubMed
    • Export Citation
  • [5]

    Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333.

    • Crossref
    • PubMed
    • Export Citation
  • [6]

    O’Donnell ML, Creamer M, Pattison P, Atkin C. Psychiatric morbidity following injury. Am J Psychiatry 2004;161:507–14.

    • Crossref
    • PubMed
    • Export Citation
  • [7]

    Kühn M, Ehlert U, Rumpf HJ, Backhaus J, Hohagen F, Broocks A. Onset and maintenance of psychiatric disorders after serious accidents. Eur Arch Psychiatry Clin Neurosci 2006;256:497–503.

    • Crossref
    • PubMed
    • Export Citation
  • [8]

    Soberg HL, Bautz-Holter E, Roise O, Finset A. Mental health and posttraumatic stress symptoms 2 years after severe multiple trauma: self-reported disability and psychosocial functioning. Arch Phys Med Rehabil 2010;91:481–8.

    • Crossref
    • PubMed
    • Export Citation
  • [9]

    Schweininger S, Forbes D, Creamer M, McFarlane AC, Silove D, Bryant RA, O’Donnell ML. The temporal relationship between mental health and disability after injury. Depress Anxiety 2015;32:64–71.

    • Crossref
    • PubMed
    • Export Citation
  • [10]

    Maes M, Mylle J, Delmeire L, Altamura C. Psychiatric morbidity and comorbidity following accidental man-made traumatic events: incidence and risk factors. Eur Arch Psychiatry Clin Neurosci 2000;250:156–62.

    • Crossref
    • PubMed
    • Export Citation
  • [11]

    Shalev AY, Freedman S, Peri T, Brandes D, Sahar T, Orr SP, Pitman RK. Prospective study of posttraumatic stress disorder and depression following trauma. Am J Psychiatry 1998;155:630–7.

    • Crossref
    • PubMed
    • Export Citation
  • [12]

    Zatzick DF, Jurkovich GJ, Gentilello L, Wisner D, Rivara FP. Posttraumatic stress, problem drinking, and functional outcomes after injury. Arch Surg 2002;137:200–5.

    • Crossref
    • PubMed
    • Export Citation
  • [13]

    Brattström O, Eriksson M, Larsson E, Oldner A. Socio-economic status and co-morbidity as risk factors for trauma. Eur J Epidemiol 2015;30:151–7.

    • Crossref
    • PubMed
    • Export Citation
  • [14]

    McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine 2002;27:2564–73.

    • Crossref
    • PubMed
    • Export Citation
  • [15]

    Manchikanti L, Helm S, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician 2012;15:ES9–38.

    • PubMed
    • Export Citation
  • [16]

    Florence C, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care 2016;54:901–6.

    • Crossref
    • PubMed
    • Export Citation
  • [17]

    Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a national institutes of health pathways to prevention workshop. Ann Intern Med 2015;162:276–86.

    • Crossref
    • PubMed
    • Export Citation
  • [18]

    Dersh J, Mayer TG, Gatchel RJ, Polatin PB, Theodore BR, MayerEAK. Prescription opioid dependence is associated with poorer outcomes in disabling spinal disorders. Spine 2008;33:2219–27.

    • Crossref
    • PubMed
    • Export Citation
  • [19]

    Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 2014;348:1–10.

  • [20]

    Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med 2016;176:1286–93.

    • Crossref
    • PubMed
    • Export Citation
  • [21]

    Svenska Traumaregistret. SweTrau Årsrapport 2015. Available at: http://rcsyd.se/swetrau/dokument.

  • [22]

    Svenska Traumaregistret. SweTrau. From: http://rcsyd.se/swetrau.

  • [23]

    RStudio Team. RStudio: Integrated Development for R. Boston, MA: RStudio, Inc., 2016. URL http://www.rstudio.com/.

  • [24]

    Muller AE, Clausen T, Sjøgren P, Odsbu I, Skurtveit S. Prescribed opioid analgesic use developments in three Nordic countries, 2006–2017. Scand J Pain 2019;19:345–53.

    • Crossref
    • PubMed
    • Export Citation
  • [25]

    Deyo RA, Hallvik SE, Hildebran C, Marino M, Dexter E, Irvine JM, O’Kane N, Van Otterloo J, Wright DA, Leichtling G, Millet LM. Association between initial opioid prescribing patterns and subsequent long-term use among opioid-naïve patients: a statewide retrospective cohort study. J Gen Intern Med 2017;32:21–7.

    • Crossref
    • PubMed
    • Export Citation
  • [26]

    Brat GA, Agniel D, Beam A, Yorkgitis B, Bicket M, Homer M, Fox KP, Knecht DB, McMahill-Walraven CN, Palmer N, Kohane I. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018;360:1–9.

  • [27]

    Célèrier E, Rivat C, Jun Y, Laulin JP, Larcher A, Reynier P, Simonnet G. Long-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology 2000;92: 465–72.

    • Crossref
    • PubMed
    • Export Citation
  • [28]

    Compton P, Charuvastra VC, Kintaudi K, Ling W. Pain responses in methadone-maintained opioid abusers. J Pain Symptom Manage 2000;20:237–45.

    • Crossref
    • PubMed
    • Export Citation
  • [29]

    Younger JW, Chu LF, D’Arcy NT, Trott KE, Jastrzab LE, Mackey SC. Prescription opioid analgesics rapidly change the human brain. Pain 2011;152:1803–10.

    • Crossref
    • PubMed
    • Export Citation
  • [30]

    Grace PM, Strand KA, Galer EL, Urban DJ, Wang X, Baratta MV, Fabisiak TJ, Anderson ND, Cheng K, Greene LI, Berkelhammer D, Zhang Y, Ellis AL, Yin HH, Campeau S, Rice KC, Roth BL, Maier SF, Watkins LR. Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation. PNAS 2016;113:E3441–50.

    • Crossref
    • PubMed
    • Export Citation
  • [31]

    Grace PM, Maier SF, Watkins LR. Opioid-induced central immune signaling: implications for opioid analgesia. Headache 2015;55:475–89.

    • Crossref
    • PubMed
    • Export Citation
  • [32]

    Fredheim OMS, Mahic M, Skurtveit S, Dale O, Romundstad P, Borchgrevink PC. Chronic pain and use of opioids: a population-based pharmacoepidemiological study from the Norwegian Prescription Database and the Nord-Trøndelag Health Study. Pain 2014;155:1213–21.

    • Crossref
    • PubMed
    • Export Citation
  • [33]

    Soderstrom CA, Smith GS, Dischinger PC, McDuff DR, Hebel JR, Gorelick DA, Kerns TJ, Ho SM, Read KM. Psychoactive substance use disorders among seriously injured trauma center patients. JAMA 1997;277:1769–74.

    • Crossref
    • PubMed
    • Export Citation
  • [34]

    Rivara FP, Jurkovich GJ, Gurney JG, Seguin D, Fligner CL, Ries R, Raisys VA, Copass M. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg 1993;128:907–13.

    • Crossref
    • PubMed
    • Export Citation
Purchase article
Get instant unlimited access to the article.
$42.00
Log in
Already have access? Please log in.


or
Log in with your institution

Journal + Issues

Search