Effect of alternatives to opiates program on discharge opioid prescribing in trauma patients

ABSTRACT

INTRODUCTION: Opioid overdose deaths increased over two decades, with the incidence accelerated further during the COVID-19 pandemic. While opioids remain mainstay for trauma-related pain management, organizations are focused on reducing use. This study aimed to determine if a hospitalwide Alternatives to Opiates (ALTO) program reduced opioid prescribing at discharge after trauma. METHODS: A single-center, retrospective analysis of patients ≥18 years old admitted for ≥24 hours with primary diagnosis of traumatic injury between August 1, 2018 - October 31, 2019 was performed. Admissions before July 1, 2019, represent the control group, whereas admissions on/after represent the ALTO group. Patients with alcohol or polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. The primary outcome was incidence of opioid prescribing at discharge. Secondary outcomes were percent with in-hospital non-opioid and multimodal analgesia, and hospital and intensive care unit (ICU) length of stay (LOS). A sample size of 129 patients was needed to observe a 30% reduction in primary outcome and maintain 80% power to detect a statistically significant difference using alpha < 0.05. RESULTS: A total of 703 patients were included, 471 in the control and 232 in the ALTO groups. Mean age was 59±22 years and 58.7% were male. Mean initial Injury Severity Score (ISS) was 9.1±7.7 and Charlson Comorbidity Index (CCI) was 2.7±2.7. In-hospital opioid prescribing was higher (70.4% vs. 87.5%, p< 0.0001), and opioid discontinuation at hospital discharge occurred less frequently (60.5% vs. 56.2%, p=0.1237) after ALTO implementation. Surgical intervention, lack of ICU admission, ISS ≥9 and CCI ≤1 was associated with lower incidence of opioid discontinuation at discharge in both groups. Most patients received nonopioid (93.6 vs. 98.7%, p=0.0051) and multimodal analgesia (84.3% vs. 87.5%, p=0.3083) during hospitalization. Median hospital LOS [5(3-9) vs. 4(3-7), p=0.3427] and ICU LOS [2(0-4) vs. 3(2-5), p=0.3461] were similar. CONCLUSIONS: Opioids remain mainstay for traumarelated pain management. In our study, ALTO was not associated with a reduction in in-hospital opioid prescribing or at discharge. Identification and implementation of strategies to further reduce opioid prescribing at discharge in trauma patients are needed.