The Real Impact of Opioid Dependence in Burn Patients

While pain management in burn patients often involves the use of opioids, this can lead to dependence or abuse, which only furthers the severity of the overall cost burden and can affect patients’ treatment outcomes as well.

But to what degree is opioid use in burn patients affecting these issues?

Peluso et al. analyzed the impact of opioid dependence in burn patients in the U.S. to determine its effect on utilization of healthcare resources, in-hospital mortality and 30-day readmission rate.

Determining the Effects of Opioid Use in Burn Patients

Peluso et al. analyzed the characteristics of 22,348 burn injury patients, 597 of which were opioid dependent from the 2016 National Readmissions Database, the largest nationally representative inpatient database in the U.S.

Opioid-dependent burn patients led to significant increases in:

Utilization of Hospital Resources/Costs

• • Number of procedures required: The overall rates of wound debridement, debridement of subcutaneous tissue and fascia, escharotomy, debridement of muscle and debridement of bone were higher among opioid-dependent burn patients than patients without opioid dependence.
  • Length of hospital stay: The mean length of hospital stay for patients with opioid dependence was significantly higher than for patients without opioid-dependence, at 13.8 days and 8.1 days respectively.
  • Hospitalization charges and costs: For opioid-dependent burn patients, the mean total hospitalization charges and costs were higher at $174,306 and $46,760 For patients without opioid dependence, mean charges and costs were $123,092 and $30,858.

Readmission

• • Readmission rate: After adjusting for confounders, the 30-day all-cause readmission rate was found to be 83% higher in opioid-dependent burn patients than in non-opioid-dependent patients.
  • Cause for readmission: Sepsis was the main cause for readmission in both groups.
    • • However, for opioid-dependent burn patients, three out of the ten most common reasons for readmission were opioid-related
      • The study authors note that in-hospital and post-discharge prescription of opioids makes up the largest proportion of all causes of opioid abuse

Patient Outcomes

• • Mortality: In-hospital mortality rates were similar for both groups, at 1% for opioid-dependent burn patients and 3.3% for patients without opioid-dependence
  • However, patients with opioid-dependence were more than three times likely to leave against medical advice than those without opioid-dependence.

Minimizing Opioid Use in Burn Patients

Given Peluso et al.’s findings, how can hospitals work to reduce the number of opioids prescribed to burn patients without increasing their pain levels?

In their 2021 retrospective cohort study, Donthula et al. implemented two opioid-minimizing acute burn pain protocols at their hospital to determine whether these methods could decrease opioid exposure without significantly increasing patients’ pain scores.

The two protocols consisted of the following:

• • Multimodal pain regimen – this was used for managing background and breakthrough pain with scheduled acetaminophen, gabapentin, and naproxen with oxycodone as-needed. If additional adjuncts were needed, patients were given subdissociative ketamine infusions, scheduled opioids (methadone or extended-release oxycodone), dronabinol, hydroxyzine or amitriptyline.
  • Procedural pain protocol – used for large dressing changes, this protocol involved the use of ketamine, propofol or dexmedetomidine for minimal to moderate sedation.

The study authors compared 496 patients who had been admitted prior to the implementation of these protocols (pre-group) to 174 patients who had been admitted after the protocols had been implemented (post-group).

The post group experienced a significant reduction in opioid exposure with respect to total morphine milligram equivalents (MMEs), MMEs/day, and total MMEs for background, breakthrough, and procedural pain. The post-group also had a lower risk of being prescribed opioids at discharge.

There were also found to be no statistically or clinically significant differences in the Numeric Rating Scale (NRS), Behavior Pain Assessment Scale (BPAS), or average normalized pain score in the post-group. There continued to be no difference in normalized average pain score even after adjusting for TBSA.

The study authors note that while their pain protocol was largely based on their own experiences, these new methods align with the American Burn Association’s 2020 guidelines.

Overall, they concluded that the implementation of their new protocols led to lower exposure to opioids without negatively affecting pain scores. However, they acknowledge that further research into other adjuncts for acute burn pain should be a focus in the future.

One such adjunct is virtual reality, which researchers have found can provide as effective pain relief as opioids during painful dressing changes in burn care.