Predictors of Long-Term Opioid Use After Hospitalization for Traumatic Injury in a Racially and Ethnically Diverse Population: A 12-Month Prospective Observational Study

Firearm injury survivors report extreme high risk for poor physical and mental health outcomes early after hospital discharge necessitating multidisciplinary care

Background

Up to 20-40% of survivors of any traumatic injury develop post-traumatic stress disorder (PTSD) or depression after injury. Firearm injury survivors may be at even higher risk for adverse outcomes. We aimed to characterize PTSD and depression risk, pain symptoms, and ongoing functional limitations in firearm injury survivors early after hospital discharge.

Methods

Firearm injury survivors seen in the Trauma Quality of Life (TQOL) outpatient follow-up clinic 1-2 weeks after discharge were invited to participate in a survey assessing both mental and physical health outcomes. The survey included the Brief Pain Inventory (BPI), the Injured Trauma Survivor Screen (ITSS), the Beck Depression Inventory (BDI), the PTSD Checklist for DSM-5 (PCL-5), and the 12-item Short Form Survey Physical Health component (SF-12).

Results

306 patients were seen in the TQOL Clinic, and 175 responded to the survey. The mean age was 32 years (SD=12), 81% were male, and 79% were black. On the ITSS, 69% and 48% of patients screened risk positive for PTSD and depression, respectively. Patients reported mild depression symptoms with an average BDI score of 14.3 (SD=11.8) and elevated PTSD symptoms with an average PCL-5 score of 43.8 (SD=12.8). Patients with severe BPI scores were more likely to screen positive for depression and PTSD. Respondents scored >2 SD below the US national average on the SF-12 for physical quality of life (M=28.7). 12% of patients were at risk across all four domains of pain, PTSD, depression, and physical function.

Conclusion

Early after discharge, over two-thirds of firearm injury survivors were at risk for the development of PTSD, nearly half were at risk of depression, and physical function was significantly decreased. Trauma centers need to prioritize early, outpatient multidisciplinary care to treat and prevent the development of poor chronic physical and mental health for firearm injury survivors.

Level of evidence

III.

Community Opioid Dispensing after Injury (CODI): Cohort characteristics and opioid dispensing patterns

BACKGROUND

Despite a focus of opioid-related research internationally, there is limited understanding of long-term opioid use in adults following injury. We analysed data from the 'Community Opioid Dispensing after Injury' data linkage study.

AIMS

This paper aims to describe the baseline characteristics of the injured cohort and report opioid dispensing patterns following injury-related hospitalisations.

METHODS

Retrospective cohort study of adults hospitalised after injury (ICD-10AM: S00-S99, T00-T75) in Queensland, Australia between 1 January 2014 and 31 December 2015, prior to implementation of opioid stewardship programs. Data were person-linked between hospitalisation, community opioid dispensing and mortality collections. Data were extracted for 90-days prior to the index hospital admission, to establish opiate naivety, to 720 days after discharge. Median daily oral morphine equivalents (i.e., dose) were averaged for each 30-day interval. Cumulative duration of dispensing and dose were compared by demographic and clinical characteristics, stratified by drug dependency status.

RESULTS

Of the 129,684 injured adults, 61.3 % had no opioids dispensed in the 2-year follow-up period. Adults having any opioids dispensed in the community (38.7 %) were more likely older, female, to have fracture injuries and injuries with a higher severity, compared to those with no opioids dispensed. Longer durations and higher doses of opioids were seen for those with pre-injury opioid use, more hospital readmissions and repeat surgeries, as well as those who died in the 2-year follow-up period. Median dispensing duration was 24-days with a median daily end dose of 13 oral morphine equivalents. If dispensing occurred prior to the injury, duration increased 10-fold and oral morphine equivalents doubled. Adults with a documented dependency prior to, or after, the injury had significantly longer durations of use and higher doses than the rest of the cohort receiving opioids. Approximately 7 % of the total cohort continued to be dispensed opioids at 2-years post injury.

CONCLUSION

This is a novel population-level profile of opioid dispensing patterns following injury-related hospitalisation, described for the time period prior to the implementation of opioid stewardship programs and regulatory changes in Queensland. Detailed understanding of this pre-implementation period is critical for evaluating the impact of these changes moving forward.

Pain management in trauma: the need for trauma-informed opioid prescribing guidelines

Background/objectives

Surgical populations and particularly injury survivors often present with complex trauma that elevates their risk for prolonged opioid use and misuse. Changes in opioid prescribing guidelines during the past several years have yielded mixed results for pain management after trauma, with a limiting factor being the heterogeneity of clinical populations and treatment needs in individuals receiving opioids. The present analysis illuminates this gap between clinical guidelines and clinical practice through qualitative feedback from hospital trauma providers and unit staff members regarding current opioid prescribing guidelines and practices in the setting of traumatic injury.

Methods

The parent study aimed to implement a pilot screening tool for opioid misuse in four level I and II trauma hospitals throughout Wisconsin. As part of the parent study, focus groups were conducted at each study site to explore the facilitators and barriers of implementing a novel screening tool, as well as to examine the current opioid prescribing guidelines, trainings, and resources available for trauma and acute care providers. Focus group transcripts were independently coded and analyzed using a modified grounded theory approach to identify themes related to the facilitators and barriers of opioid prescribing guidelines in trauma and acute care.

Results

Three major themes were identified as impactful to opioid-related prescribing and care provided in the setting of traumatic injury; these include (1) acute treatment strategies; (2) patient interactions surrounding pain management; and (3) the multifactorial nature of trauma on pain management approaches.

Conclusion

Providers and staff at four Wisconsin trauma centers called for trauma-specific opioid prescribing guidelines in the setting of trauma and acute care. The ubiquitous prescription of opioids and challenges in long-term pain management in these settings necessitate additional community-integrated research to inform development of federal guidelines.

Level of evidence

Therapeutic/care management, level V.