Change in opioid and analgesic use for headaches after aneurysmal subarachnoid hemorrhage over time

Background: Severe headache, a hallmark of aneurysmal subarachnoid hemorrhage (aSAH), affects up to 90% of patients during hospitalization. Opioids remain the guideline recommended mainstay of acute therapy despite their significant side effects and potential for tolerance and addiction. We evaluated time trends in opioid prescriptions, hypothesizing a decline with increasing recognition of the opioid crisis.

Methods: We performed a retrospective review of patients with aSAH admitted to a single tertiary care center between 2012 and 2019 and included patients with Hunt-Hess-Grade≤3 who were able to verbalize pain scores. Collected variables included mean and maximum daily headache scores, aneurysm treatment modality, and daily analgesic medication doses.

Results: Of 340 patients with aSAH, 114 (86 from 2012-2016 and 28 from 2017-2019) were included. Of the included patients, 86/114 (75.4%) were female. Patients in the 2012-2016 had a median age of 55 compared to 63 in the 2017-2019 group (P=0.02). Otherwise, there was no significant difference in demographic data including time in hospital, treatment option utilized, or aneurysm characteristics. Maximal daily headache score ranged from 6 to 8 for 2012-2016 and 5 to 8 for 2017-2019 cohorts. Average oral morphine equivalents (in mg) administered during hospitalization were similar between groups (2012-2016: 251±345 95% CI [178,323]; 2017-2019: 207±237 95% CI [119,295]; P=0.319). When prescribed, doses of opioids provided at discharge were less in the more recent group (2012-2016: 84.4±78.9 95% CI [57.5, 111]; 2017-2019: 38.1±20.2 95% CI [33.7, 42.5]; P=0.004) CONCLUSION: Despite recognition of important drawbacks of opioid use for headache control, and efforts to reduce opioid use during hospitalization, we found that utilization during hospitalization for SAH did not decrease over time. Maximal headache scores remained similar in the studied time periods, indicative of insufficient pain relief. This points out a pressing need to further investigate alternative opioid and narcotic sparing strategies for patients with SAH.