Pain from burn injuries can be challenging to treat and remains one of the most severe forms of trauma a patient can endure, explains Sierra R. Young, PharmD, BCCCP.  “Patients with burn injuries experience background, breakthrough, and procedural pain during dressing changes,” she says. “As a result, they receive significantly more opioids per day than non-surgical hospitalized patients.”

Studies on burn pain management, Dr. Young notes, are limited based on design, sample size, and external validity. “Clinical guidelines on burn pain management lack evidence and uniformity,” she adds. “Recent literature reviews have recommended a multimodal approach for the successful treatment of burn pain to help decrease opioid use and to mitigate opioid-related adverse effects. However, the effect of multimodal therapy on opioids received and pain control in this patient population is not well understood.”

For a paper published in the Journal of Burn Care & Research, Dr. Young and colleagues examined the impact of multimodal therapy on postoperative pain control in a burn intensive care unit. They conducted a retrospective cohort study of patients (n = 98 non-multimodal group; n = 97 multimodal group) admitted to a burn unit in a tertiary medical center.

Durability of Multimodal Analgesia Not Well Known

The study team focused on the first 5 days after an excision and grafting surgery, Erin Louie, Pharm D, BCPS, BCCCP, explains. “This is when patients are likely to experience the greatest amount of uncontrolled pain,” she says. “We found a clinically important reduction (28%) in opioid exposure (oral morphine equivalents [OMEs]) with the use of multimodal analgesia without compromising pain control. While it is suspected that multimodal analgesia provides a sustained response throughout hospitalization, the durability of these agents is still not well known. Therefore, appropriate clinical monitoring while receiving these agents and eventual de-escalation as the pain resolves are important.”

Although there are likely many benefits to reducing opioid exposure in this patient population, wound healing remains the driving force behind clinical endpoints such as ICU admittance or hospital length of stay, notes Dr. Louie. “While pain control remains an important factor for adequate wound healing, there are numerous other factors to consider, such as infection control, micronutrient supplementation, and hypermetabolic state.”

Clinical Management by Multidisciplinary Team Recommended

Jeremiah Duby, PharmD, BCCCP, BCPS, FCCM, expresses surprise at the cumulative opioid doses that patients in the study received. “In both the multimodal and non-multimodal analgesia groups, patients were given hundreds of milligrams of OME per day, suggesting that completely abolishing pain in this patient population may be unachievable,” he says. “However, the effect of multimodal analgesia appeared immediate and sustained throughout the 5-day post-operative period (Figure).”

Practicing a protocolized “cookie cutter” approach to burn pain management may not always achieve adequate results for all patients, according to Dr. Young. “It is recommended that clinicians who care for burn patients utilize a toolbox of individualized multimodal analgesia through a multidisciplinary approach in order to improve postoperative pain control,” she says. “It is also important to allow the type of pain to help guide the approach to treatment. The use of multiple agents, higher doses, and longer courses of therapy likely increase the risk of adverse drug effects. Careful clinical management by a multidisciplinary team—to titrate, monitor, and de-escalate—is necessary to maximize potential benefit and minimize harm.”

In future research, Dr. Young and colleagues would like to see a prospective study that allows for comparisons and conclusions on the additive effects of multimodal agents and to determine which agent(s) and dose(s) provide the most benefit. “It is unknown if the use of multimodal analgesia has a sustained effect beyond the short-term postoperative period,” she says. “Additionally, further studies examining the long-term safety of these agents are needed.”