Introduction: Pain control is key in care of burn patients and opioids are a cornerstone of pain management [1]. As increased scrutiny and restrictions regarding opioids grow in the United States, there is an effort to address opioid use in surgical patients in order to decrease opioid dependence, overdose, and potential negative side effects [2]. Geriatric patients are an important and complex population to consider regarding pain control. Given the increased side effects of opioids in this patient population, it is especially important to limit their use; however, pre-existing comorbid conditions, such as liver or renal disease, limit the use of non-steroidal anti-inflammatories (NSAIDs) and acetaminophen [3]. Managing pain in the elderly is a balancing act due to difficult post-operative pain control and challenges with delirium in this patient population [4, 5]. There is currently little existing data in the burn literature examining prescribing practices for pain control in the elderly. This study aims to retrospectively characterize pain management practices in geriatric patients admitted to our burn center.

Methods: This is a retrospective cohort of patients ages 65 and over with burns <20% total body surface area (TBSA) admitted to the burn step down unit from July 1, 2014 to December 31, 2019. Primary outcome was the percentage of patients receiving opioid prescriptions on discharge. Secondary outcomes included inpatient opioid use, median daily doses in oral morphine milligram equivalents (OME) as well as use of non-opioid adjuncts for pain management. The planned sample size for this retrospective review is 200 patients.

Results: A preliminary sample of 30 patients had a median age of 72.4 years (Interquartile range [IQR] 69.36-79.72) and a median total body surface area burn of 4.0% (IQR 2.3-6.8%). Most common mechanism of burn was thermal (86.7%). Forty-four percent of patients had full thickness burns. On the date prior to discharge, 57% of patients received opioids at a median daily dose of 30 OME (IQR 20-30). On discharge 70% of patients received an opioid prescription; for these patients a mean of 22.5 (IQR 5-30) OME was prescribed. The most commonly prescribed non-opioid medication was acetaminophen (70% of patients inpatient and 43% on discharge). Additionally, both NSAIDs and gabanoid agents were prescribed quite infrequently while inpatient (6.7% and 13.3%, respectively) and on discharge (13.3% and 13.3%, respectively).

Conclusions: Currently, epidemiologic data regarding the use of opioids and other pain medications in geriatric patients with small burns is lacking in the literature. Our study found an increase in opioid prescription at the time of discharge from the hospital when compared to inpatient opioid use. The most commonly prescribed analgesic adjunct was acetaminophen. Other widely used non-opioid adjuncts in younger adults such as NSAIDs and gabanoid medications were infrequently prescribed, likely due to concern for adverse events in the elderly. These preliminary results reveal a deviation in opioid prescribing practices on discharge in elderly patients upon discharge, suggesting a potential need for better transitions of care from the inpatient to the outpatient setting.

References and Resources

1. James DL, Jowza M: Principles of Burn Pain Management. Clin Plast Surg 2017, 44(4):737-747.
2. Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E: Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg 2017, 125(5):1733-1740. 3. Naples JG, Gellad WF, Hanlon JT: The Role of Opioid Analgesics in Geriatric Pain Management. Clin Geriatr Med 2016, 32(4):725-735.
3. Tighe PJ, Le-Wendling LT, Patel A, Zou B, Fillingim RB: Clinically derived early postoperative pain trajectories differ by age, sex, and type of surgery. Pain 2015, 156(4):609-617.
4. Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER: The impact of postoperative pain on the development of postoperative delirium. Anesth Analg 1998, 86(4):781-785.
5. Naples JG, Gellad WF, Hanlon JT: The Role of Opioid Analgesics in Geriatric Pain Management. Clin Geriatr Med 2016, 32(4):725-735.

Opioid Use and Pain Control in Geriatric Burn Patients Figures

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