A Multimodal Approach to Treating Burn Injury Pain
According to a study published in Burns Open, a multimodal pain regimen, featuring a blend of pharmacologic and nonpharmacologic agents, is significantly important in treating patients with burn injury-induced pain (BIP). While opioids are a centerpiece of burn pain management, adjunctive medications are needed for successful treatment because of the complexities of burn pain.
The severity of burn injuries in the United States is profoundly impactful. “Nearly half a million burn injuries occur throughout the United States every year,” the authors noted. “Burn injury can produce the most physically debilitating and traumatic injuries due to their systemic effects on the body that can lead to significant morbidity and mortality.”
Management of BIP requires a holistic understanding of the pain’s mechanisms and the application of nonopioid pain management techniques. According to the authors, “one of the most debilitating aspects one observes during the care of burn injury subjects is the pain that these patients experience from the onset of injury, during the recovery and the rehabilitation period, and in some instances, even beyond full wound and hospital discharge.”
There are 11 million patients around the world who experience a burn injury every year. | © image credit: mlangsen / stock.adobe.com
Twelve million patients around the world experience a burn injury every year, and various treatment options are yet undeveloped for managing this kind of severe pain. “Burn injury-precipitated pain is a unique and debilitating experience that adds up to the severity of burn injuries, a severe acute inflammatory condition and intense nerve injury.”
Identifying the mechanisms leading to pain, as well as the most beneficial and least invasive treatment options, is crucial in the quest to better understand and manage BIP. Researchers also highlighted the role neuro-immune interaction plays in the presentation of pain in patients with burn injuries. They focused on spinal microglia activation as a target for BIP treatment. Outside of treatments for BIP, microglia activation has also been identified as a target for spinal cord pain treatment. According researchers, “As the injury advances, microglia undergo activation and secrete pro-inflammatory cytokines, resulting in the emergence of neuropathic pain,” wrote authors of a study published in Experimental Neurology
“Microglia, the resident macrophages of the central nervous system (CNS), together with the peripheral macrophages, comprise the innate immune system. During damage or environmental changes, they respond by transforming and/or migrating to the area of injury,” the authors wrote. “Burn injury leads to systemic and neuro-inflammatory responses. Burn injury induces microglial proliferation and activation, together with pain. Researchers then moved to BIP treatment and the important role opioids play. Indeed, opioids have been used frequently for the treatment of BIP due to their efficacy and access compared with other analgesic medications. However, since many patients with BIP inevitably require higher and higher doses of opioids, multimodal approaches with pharmacologic and nonpharmacologic agents are crucial to the treatment of BIP.”
The problems with opioid dependency, especially, are well-documented in the U.S. The CDC reports that around 932,000 people have died since 1999 from a drug overdose and of those, 75% involved an opioid.
A number of the reporting agencies in the healthcare industry suggest understanding opioids in the U.S. is crucial to understand opioid prescriptions in the case of BIP. Since dependency issues are prevalent among patients and opioid-derived medications produce several health problems, according to experts in the healthcare sector, including Johns Hopkins Medicine Hospital, opioid prescriptions are considering controversial. Attempts to balance potency and misrepresentation are crucial in creating better medicinal procedures
A multimodal pain regimen with other adjunctive non-pharmacologic agents is of utmost importance due to the multifaceted nature of BIP. This regimen should be all-encompassing and requires a thorough understanding of the anatomic, metabolic, and psychologic factors that encompass this type of pain.
“By it’s extreme nature, burn injury-induced pain is diversely associated with aberrant neural function and neuroinflammatory process. According to the authors of the study, “one of the most debilitating aspects one observes during the care of burn injury. Patients is the pain that they experience from the onset of injury, during the recovery and the rehabilitation period, and in some instances, even beyond full wound healing and hospital discharge, According to health surveys published in 2022, FL and Orlando has the 2nd and 3rd highest average inpatient lengths of stay and $11k and $12,000 in costs respectively for BIP.-
A multimodal approach involves treating and managing BIP with both pharmacologic and nonpharmacologic treatments. For the given definition, BIP may entail the development and progression of neuropathic and inflammatory pain. According to the authors, “Microglia, the resident macrophages of the central nervous system (CNS), together with the peripheral macrophages, comprise the innate immune system. During damage or environmental changes, they respond by transforming and/or migrating to the area of injury. Burn injury induces microglial proliferation and activation, together with pain.”
The CDC and FDA are often crusaders for the reduction of opioid intake. Safe consumption of opioids is dependent upon adherence to the prescription. Evidence-based multimodal approaches in conjunction with raised religious sentiments may prove crucial. They proposed virtual reality, distraction therapy, cognitive behavioral therapy, and hypnosis as promising adjunctive approaches to treating BIP.
Recent Developments in BIP Treatment
The field of BIP treatment is evolving rapidly, with numerous studies and clinical trials exploring innovative approaches. For instance, recent research has highlighted the potential of virtual reality (VR) as a nonpharmacologic adjunctive therapy. VR immersive environments can distract patients from pain and reduce anxiety, thereby enhancing the effectiveness of conventional pain management strategies. For example, a study conducted at the University of Washington found that patients undergoing VR therapy reported a 30% reduction in pain intensity compared to those who did not receive VR treatment.
Researchers also are exploring the use of neuromodulation techniques, such as transcutaneous electrical nerve stimulation (TENS) and spinal cord stimulation, to manage BIP. These methods involve the application of electrical impulses to modulate pain signals. A study published in the Journal of Pain Research demonstrated that TENS therapy significantly reduced pain in patients with severe burn injuries, particularly those with neuropathic pain components. Furthermore, it is suggested that nonopioid techniques that forgo ancestral pain management like ice packs should be utilized in treating and managing BIP.
A Case Study of Successful BIP Management
In Texas, a 35-year-old patient with severe burns covering 40% of his body underwent a multimodal pain management regimen at a specialized burn center. The treatment plan included a combination of opioids, nonopioid analgesics, and nonpharmacologic interventions such as VR therapy and cognitive behavioral therapy. The patient’s pain was closely monitored, and adjustments were made to the treatment regimen based on his individual needs. Over a period of six months, the patient experienced a significant reduction in pain intensity and improved mobility, allowing him to participate in rehabilitation activities more effectively.
Future Directions and Challenges
The management of BIP poses a significant challenge due to its dynamic and variable nature. Successful treatment requires a regimented approach with multiple interventions and appropriate provider knowledge of the mechanisms of BIP. As the authors of the study noted, “A diligent approach with close attention to these factors by the healthcare team can have a significant impact on the patient’s journey from initial injury to the rehabilitation period and can substantially improve long-term outcomes. Future research could focus on nonopioid techniques to manage BIP.”
A Multimodal Approach to Treating Burn Injury Pain
Why is a Multimodal Approach Critically important in treating Burn Injury Pain (BIP)?
Q: What constitutes a multimodal approach to burn injury pain management?
A: A multimodal approach to treating Burn Injury Pain (BIP) includes a blend of pharmacologic adn nonpharmacologic treatments. While opioids are commonly used due to their efficacy, adjunctive medications and therapies are essential to address the complex nature of burn pain. Nonpharmacologic agents can include virtual reality, distraction therapy, cognitive behavioral therapy, and neuromodulation techniques like TENS (transcutaneous electrical nerve stimulation). This comprehensive approach is crucial as BIP encompasses neuropathic and inflammatory pain, requiring varied treatment strategies to manage its different aspects effectively.[1] [2]
Understanding the Impact and Mechanisms of Burn Pain
Q: How prevalent are burn injuries, and what makes their pain notably challenging to manage?
A: Approximately half a million burn injuries occur annually in the United States. The severity of thes injuries is profound due to their systemic effects on the body, leading to significant morbidity and mortality. Burn pain is challenging due to its multifaceted nature, involving aberrant neural function and neuroinflammatory processes. This pain persists from the onset of injury through recovery and rehabilitation, and sometiems beyond hospital discharge. Understanding the mechanisms behind burn pain, including neuro-immune interactions and microglial activation, is essential for effective management.[3]
Q: How does microglial activation relate to burn pain?
A: Burn injuries induce systemic and neuro-inflammatory responses, triggering microglial proliferation and activation. Microglia, the CNS’s resident macrophages, play a significant role in the innate immune response to injury. as the injury progresses, microglia secrete pro-inflammatory cytokines initiating neuropathic pain. Targeting microglial activation presents a promising avenue for BIP treatment, emphasizing the need for multifaceted therapeutic strategies.[1]
The Role of Opioids and Alternatives in BIP Management
Q: Why are opioids controversial in BIP management, and what are the alternatives?
A: Though opioids are widely used for their potency in managing BIP, they often lead to higher doses, contributing to dependency issues. With around 932,000 opioid-related deaths in the U.S. as 1999, the medical community urges a cautious approach to opioid prescriptions. Multimodal strategies involving nonopioid medications and nonpharmacologic therapies are vital alternatives for reducing reliance on opioids. Nonopioid techniques, such as neuromodulation, VR-based distraction therapy, and cognitive behavioral therapy, offer effective adjunctive measures for comprehensive pain management.[2]
Recent Developments in BIP Treatment
Q: What novel approaches are being explored in the treatment of BIP?
A: Recent innovations in BIP treatment include virtual reality as a nonpharmacologic therapy, which helps distract patients and reduce anxiety, thereby improving traditional pain management methods. Studies, such as those conducted at the University of Washington, have shown VR therapy to reduce pain intensity significantly. Neuromodulation techniques, such as TENS, are also under exploration, showing promise in managing neuropathic pain in severe burn injuries.These advancements highlight the ongoing efforts to find less invasive and effective pain management strategies.[3]
Case Study and Future Directions
Q: Can you provide an example of successful multi-modal BIP management?
A: A case study from Texas demonstrates a successful multimodal pain management regimen for a patient with severe burns covering 40% of his body. The regimen included opioids,nonopioid analgesics,and nonpharmacologic interventions like VR therapy and cognitive behavioral therapy. Over six months, these combined therapies resulted in considerable pain reduction and enhanced rehabilitation participation, underscoring the importance of tailored, comprehensive care plans.[3]
Q: what are the future challenges in BIP management?
A: The dynamic nature of BIP poses ongoing challenges in its management. Effective treatment requires a regimented, multifaceted approach, with ongoing monitoring and adjustments based on individual patient needs. Future research is expected to delve deeper into nonopioid techniques, emphasizing the importance of understanding BIP’s underlying mechanisms and exploring emerging therapies for improved long-term outcomes.[3]
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