Author: David C. Holzman
The potential for better outcomes in the treatment of pain for burn patients could come from greater use of nonopioid adjuvant pain medications, such as ketamine, according to researchers of a new study.
Adjuvant pain medications can reduce the amount of opioids necessary to mitigate pain, but most patients aren’t receiving them, according to the trial investigators. In a retrospective analysis of 664 patients who were admitted to the University of Kansas Medical Center’s burn injury unit over a two-year period, only 30% of patients received adjuvant medications, and just 12% received neuropathic pain medications, reported lead author Joshua Cleveland, MD, a resident at the University of Kansas Medical Center, in Kansas City.
Nearly 21% of patients admitted to the burn injury unit were using opioids before admission, and 12.7% of patients had a history of chronic pain.
The data showed the value of adjuvant medications, according to the researchers. Patients who received a ketamine infusion had a 40% reduction in oral morphine equivalents from day of admission to discharge.
The study represented an effort “to see what the trend is for opioids and other nonopioid medications at the burn unit,” said principal investigator Andrea Nicol, MD, an assistant professor of anesthesia at the University of Kansas School of Medicine. “The main conclusion is that opioids tend to be the mainstay for treatment in burn injury patients, and the amount of adjuvant analgesics was a lot lower than expected. At any given time, only 30% to 50% [of burn patients] were getting other medication than opioids.”
“Traditionally the gold standard has been to treat these patients with opioids, which we all know is not ideal for a number of reasons,” Dr. Cleveland said during his presentation. “You have the hyperalgesia, the respiratory depression and addiction.”
There is a lack of research and published results on the use of adjuvant analgesics despite the prevalence of nonopioid multimodal pain treatment practiced in most places, according to Eugene R. Viscusi, MD, the chief of pain medicine in the Department of Anesthesiology at Sidney Kimmel Medical College of Thomas Jefferson University, in Philadelphia; the president-elect of ASRA; and a member of the Anesthesiology News editorial advisory board.
“There is a low utilization of antineuropathic agents, even though burning signaling is a common complaint. So we routinely recommend inclusion,” said Dr. Viscusi, who was not involved in the research. He also highlighted the significant reduction of opioid use when ketamine was added to the treatment, as reported by the investigators. “Given that this is seen in other pain scenarios, it isn’t surprising that it would work with burn patients.
“Ketamine is our most commonly employed infusion for analgesia with the burn patients,” Dr. Viscusi said. “We also successfully offer supplemental bolus doses for dressing changes.
“I was a little surprised that IV lidocaine infusions were missing in this review,” he said. “There is some evidence to support its use in burn patients.”
Burn injuries not only are sources of intense acute pain but can result in chronic pain, as well as stress-related disorders. In the United States, an estimated 1.25 million people sustain burn injuries annually, according to the poster.
But ketamine looks particularly promising, Dr. Nicol said in reference to the presentation. The researchers reported a 40% drop in opioid use during hospitalization among patients who received it, compared with only 15% in those who received other medications.
“We need to do a better job of utilizing medications that aren’t opioids so that we can decrease as much as possible the use of opioids,” Dr. Nicol said.
The research (abstract 4515) was originally presented during the 2017 annual pain medicine meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA).