Efficacy and feasibility of opioids for burn analgesia: An evidence-based qualitative review of randomized controlled trials

doi:10.1016/j.burns.2017.10.012

Burns

Volume 44, Issue 2, March 2018, Pages 241-248

https://doi.org/10.1016/j.burns.2017.10.012 Get rights and content

Highlights

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There is no comprehensive review published to discuss the specific utility of opioids in burns.
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Topical morphine could potentially decrease pain, analgesics use, and side effects associated with systemic opioids.
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OTFC was equivalent or even preferable to oral morphine, hydromorphone and oxycodone in burn analgesia for children.
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Intranasal fentanyl(INF) was equivalent to oral morphine in the burn wound care both in adult and pediatric patients.
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Burn sizes of patients studied in this review ranged from 1% to 62%, and the majority of burns were superficial.

Abstract

Opioids are commonly used for burn analgesia, but no comprehensive reviews have been published on such use. We aimed to assess the literature regarding the effectiveness and side effects of opioids both in adult and pediatric burn patients. We conducted a systematic search of the PubMed, Embase, Cochrane, and Web of Science databases. Information on study characteristics, results, and interventions was extracted. The review identified nine studies that satisfied the inclusion criteria. Burn sizes of patients ranged from 1% to 62% of the body. The examined studies showed that dressing or cream containing morphine could potentially decrease pain, use of analgesics, and side effects associated with systemic opioid medications compared with control groups. Oral transmucosal fentanyl citrate (OTFC) was equivalent, or even preferable, to oral morphine, hydromorphone, and oxycodone in provision of analgesia for burn wound care in pediatric patients. Intranasal fentanyl (INF) was equivalent to oral morphine in burn wound care both in adult and pediatric patients. OTFC and INF could be considered as viable non-invasive analgesic alternatives to oral opioids for procedural burn pain. However, the level of evidence still seems quite uncertain because of the limited sample size.

Introduction

Burns have become a major public health concern impacting the healthcare system, and a financial burden to society, because of the high associated morbidity and mortality [1]. Management of burn injuries is highly challenging, as it may cause severe pain that is equivalent to, or even worse than, the initial burn pain. Therefore, pain control is imperative and seems to be a fundamental element of burn care procedures such as dressing changes, tubbing, debriding, and skin grafting.

Currently, the cornerstone of burn pain treatment relies on a pharmacological approach, and the gold standard of burn analgesia is opioid therapy, in particular, use of μ-receptor agonists such as morphine [1], [2]. Topically applied opioids are reported to provide a quick-acting and long-lasting analgesic effect in reducing pain associated with leg ulcers and chronic inflammatory skin conditions [3], [4], [5], [6]. Several studies have tested whether topical opioids could also significantly reduce pain associated with partial- or full-thickness burns [7], [8], [9].

However, to our knowledge, no comprehensive qualitative reviews have been published on the specific utility of opioids for burn pain. We therefore aimed to summarize the effectiveness and side-effect profile of opioids in adult and pediatric burn patients. We identified and analyzed outcome parameters such as burn-care-related pain and anxiety, use of analgesics, and side effects.

Section snippets

Data sources and search strategy

We conducted a systematic search of the PubMed, Embase, Cochrane, and Web of Science databases, using terms such as “burn” or “opioid,” in May 2017 to identify available data sources. The Supplemental Table shows the details of the search strategies. Only studies in English were included in the review. Further relevant trials were obtained by manually searching the conference abstracts and reference lists of all identified related publications to avoid omitting relevant randomized controlled

Study selection and characteristics

Through the initial database search, 654 studies were analyzed. Nine studies passed the inclusion and exclusion criteria and were identified for further data extraction [7], [8], [9], [11], [12], [13], [14], [15], [16] (Fig. 1).

Table 1 summarizes the general characteristics of the included studies, which were published between 1989 and 2007. Sample sizes of these trials ranged from 4 to 88 participants, and totaled 285 participants. Five trials focused on adults [7], [8], [9], [11], [15], four

Discussion

Owing to the paucity of studies, our review cannot more comprehensively guide practitioners in analgesia management of burn pain in adult and pediatric patients; additional work is required. Overall, we identified nine published trials comparing opioids with a placebo or with each other, involving a total of 285 burn patients. Burn sizes of participants ranged from 1% to 62%, and the majority of burns were superficial. As burn wound care procedure can inflict severe pain and anxiety on

Conclusion

This study revealed evidence supporting topical application of opioids to ameliorate burn pain. Additionally, OTFC and INF were found equivalent to oral morphine in provision of analgesia for burn wound care. However, the level of evidence for the beneficial effect of opioids still seems rather uncertain because of the limited sample size. Therefore, more RCTs in well-defined sample sizes and wider population ranges are needed to reinforce our conclusions.

Disclosures

None.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

None.

Acknowledgements

Chao Yang and Xiao-min Xu contributed equally to this work.

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Citation Excerpt :
Similarly a review done by Yang et al. which evaluated efficacy and feasibility of different types of opoids and routs of administrations concluded that oral trans-mucosal fentanyl citrate (OTFC) and INF are equally effective and preferable, to oral morphine (0.1 mg/kg), hydromorphone (60 mcg/kg), and oxycodone (0.1–0.2 mg/kg) in providing analgesia for burn pediatric patient undergoing wound care. Because of its fast acting and easy to administer effect OTFC appeared to be a promising analgesic in reducing burn wound procedural pain [13]. LOE = 1a.
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For effective management of procedural pain and accompanying anxiety during WCP in children, we recommend using non-pharmacological strategies as an adjunct with calculated dose of analgesics based on the children's analgesic requirements. We also recommend ketamine-dexmedetomidine as an effective first-line analgesic-sedation, and ketamine-propofol, propofol-remifentanil, propofol-fentanyl, and ketamine-midazolam as useful sedative-analgesic options.
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A total of 806 patients (55% White, 35% Black, 5% Hispanic, 5% Other) were included. In an adjusted analysis, no differences in opioid administration were seen by sex, burn degree, or for Blacks and Hispanics when compared with Whites. Increased MME/kg was associated with older age (10–18 years; p < 0.0001) and larger burns (>5% TBSA burned; p < 0.0001). From 2013 to 2018, median MME/kg per admission declined significantly (2013:0.21, 2018:0.09; p = 0.0103).
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ReviewEfficacy and feasibility of opioids for burn analgesia: An evidence-based qualitative review of randomized controlled trials

Highlights

Abstract

Introduction

Section snippets

Data sources and search strategy

Study selection and characteristics

Discussion

Conclusion

Disclosures

Funding

Conflict of interest

Acknowledgements

Burns

J Pain Symptom Manage

J Pain Symptom Manage

Blood

Burns

Burns

Opioid-induced hyperalgesia and burn pain

J Burn Care Res

Peripheral opioids in inflammatory pain

Arch Dis Childhood

Review
Efficacy and feasibility of opioids for burn analgesia: An evidence-based qualitative review of randomized controlled trials