M.O. Fajemisin1, S. Martinez Ugarte1, W.D. Rieger1, R. Walker Green1, C. Pedroza1, J.A. Harvin1, L.S. Kao1 1McGovern Medical School at UTHealth Houston, Division Of Trauma And Acute Care Surgery, Houston, TEXAS, USA
Introduction: Sex, racial, and ethnic disparities exist in receipt of opioids after trauma. Despite implementing a protocolized multimodal pain regimen (MMPR) at our institution in 2013, disparities remained. Subsequently, we performed the Multimodal Analgesic Strategies for Trauma (MAST) randomized controlled trial (RCT) to compare two pill-based, opioid minimizing MMPRs. Each MMPR allowed for as needed opioid dosing for breakthrough pain. We hypothesized that the MAST trial would resolve the previously noted disparities and decrease overall opioid use as defined by morphine milligram equivalents per day (MME/day).
Methods: We performed a secondary analysis of a retrospective cohort study (2013-2017) and the MAST RCT (2018-2019. Both studies enrolled adult patients (>=16 years) admitted to the trauma service at a single center. Demographics, injury details, outcomes, and pain medications were obtained from the trauma registry supplemented by chart review. Patients were grouped by race/ethnicity (White, Black, Hispanic, and Other) or by sex. Comparator groups were White race and male sex. Univariate analysis was performed to assess MME/day amongst MMPR groups. Multivariable analyses were performed adjusting for age, injury severity score (ISS), MMPR regimen, unit of admission, laparotomy surgical procedure, high risk history, long bone fractures, and mechanism of injury. The incident rate ratio (IRR), along with 95% confidence intervals and p-values, were recorded for disparity outcomes. The IRR measures the difference in the frequency of events between one group and a control, while controlling for other variables, for this study the event was 1 MME/day.
Results: A total of 5900 patients were included (4339 from the retrospective study, and 1561 from the RCT), the median age was 47 (IQR 32-62). The majority of patients were White (51.6%), followed by Hispanic (28.1%), and Black (15.8%). There were 1801 (30.5%) female patients. Disparities in receipt of opioid medications persisted in the MAST group, despite a protocolized MMPR. Black (IRR 0.58, CI 0.40-0.85, p=0.005), Hispanic (IRR 0.67, CI 0.49-0.92, p=0.01), and male (IRR 0.70, CI 0.52- 0.95, p=0.02) patients received fewer total MME per day. In the MAST trial, there were no baseline differences between racial and ethnic groups in variables related to opioid exposure, including age, ISS, or hospital length of stay. There were differences in racial and ethnic groups in regards to unit of admission and mechanism of injury (p=0.003, and p=0.001). When comparing the three time periods (pre-MMPR, 1st MMPR, and the MAST trial), there was an overall decrease in opioid use across all race/ethnicity groups.
Conclusion: Disparities persisted despite the presence of a protocolized MMPR in a RCT but decreased the administration of opioids overall. Further research should assess if these disparities have persisted post-trial.