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Elliott ZT, Mann DS, Fiorella M, Christopher V, Givens A, Martin AM, Zhan T, Curry J. Predictors of opioid requirement among patients receiving free flap reconstruction to the head and neck. Am J Otolaryngol 2023; 44:104000. [PMID: 37499343 DOI: 10.1016/j.amjoto.2023.104000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Opioids are a part of standard of care treatment of acute, severe postoperative pain. However, increased opioid requirements have been shown to be associated with increased postoperative complications, morbidity, and mortality. The aim of this study was to identify potential predictive factors associated with increased or decreased opioid requirements after free tissue transfer (FTT) to the head and neck. MATERIALS/METHODS A retrospective review was conducted on subjects who underwent head and neck reconstruction (HNR) from 2015 to 2021 at a single tertiary care center. Patients with inpatient stay over 10 days and those receiving fentanyl for sedation purposes were excluded due to EMR limitations and confounding, respectively. The total dose of opioid medication each patient received was calculated and summed using morphine milligram equivalents (MME). Statistical analysis was conducted using poisson regression and multivariable regression models. RESULTS Two hundred and ninety-one patients were included. The mean opioid requirement for all subjects was 228.6 (SD 250.0) MMEs during their entire postoperative stay and the mean length of stay was 6.0 (SD 1.7) days. An established opioid prescription prior to surgical resection was the greatest predictor of increased risk for opioid requirement according univariate and multivariate analysis 2.356 (2.321-2.392), p ≤ 0.0001 and 1.833 (1.802-1.863), p ≤ 0.0001, respectively. Fibula transfers were associated with higher opioid requirements while scapula transfers were associated with decreased opioid requirements compared to other free tissue transfer types. CONCLUSION Preoperative opioid use was associated with higher postoperative opioid requirements. Multimodal pain management (MMPM) was not associated with a decreased opioid requirement; however, further studies are needed to investigate the hierarchy, dosing, and timing of MMPM in relation to opioid requirements and pain control.
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Affiliation(s)
- Zachary T Elliott
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA.
| | - Derek S Mann
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Michele Fiorella
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Vanessa Christopher
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Alyssa Givens
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Ann Marie Martin
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA 191071, USA
| | - Joseph Curry
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
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Trakimas DR, Perez-Heydrich C, Mandal R, Tan M, Gourin CG, Fakhry C, Koch WM, Russell JO, Tufano RP, Eisele DW, Vosler PS. Peri-Operative Pain and Opioid Use in Opioid-Naïve Patients Following Inpatient Head and Neck Surgery. Front Psychiatry 2022; 13:857083. [PMID: 35873237 PMCID: PMC9305070 DOI: 10.3389/fpsyt.2022.857083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Pain management is an important consideration for Head and Neck Cancer (HNC) patients as they are at an increased risk of developing chronic opioid use, which can negatively impact both quality of life and survival outcomes. This retrospective cohort study aimed to evaluate pain, opioid use and opioid prescriptions following HNC surgery. Participants included patients undergoing resection of a head and neck tumor from 2019-2020 at a single academic center with a length of admission (LOA) of at least 24 h. Exclusion criteria were a history of chronic pain, substance-use disorder, inability to tolerate multimodal analgesia or a significant post-operative complication. Subjects were compared by primary surgical site: Neck (neck dissection, thyroidectomy or parotidectomy), Mucosal (resection of tumor of upper aerodigestive tract, excluding oropharynx), Oropharyngeal (OP) and Free flap (FF). Average daily pain and total daily opioid consumption (as morphine milligram equivalents, MME) and quantity of opioids prescribed at discharge were compared. A total of 216 patients met criteria. Pain severity and daily opioid consumption were comparable across groups on post-operative day 1, but both metrics were significantly greater in the OP group on the day prior to discharge (DpDC) (5.6 (1.9-8.6), p < 0.05; 49 ± 44 MME/day, p < 0.01). The quantity of opioids prescribed at discharge was associated with opioid consumption on the DpDC only in the Mucosal and FF groups, which had longer LOA (6-7 days) than the Neck and OP groups (1 day, p < 0.001). Overall, 65% of patients required at least one dose of an opioid on the DpDC, yet 76% of patients received a prescription for an opioid medication at discharge. A longer LOA (aOR = 0.82, 95% CI: 0.63-0.98) and higher Charlson Comorbidity Index (aOR = 0.08, 95% CI: 0.01-0.48) were negatively associated with receiving an opioid prescription at the time of discharge despite no opioid use on the DpDC, respectively. HNC patients, particularly those with shorter LOA, may be prescribed opioids in excess of their post-operative needs, highlighting the need the for improved pain management algorithms in this patient population. Future work aims to use prospective surveys to better define post-operative and outpatient pain and opioid requirements following HNC surgery.
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Affiliation(s)
- Danielle R Trakimas
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Carlos Perez-Heydrich
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Rajarsi Mandal
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Marietta Tan
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Christine G Gourin
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Carole Fakhry
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Wayne M Koch
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Jonathon O Russell
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Ralph P Tufano
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - David W Eisele
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Peter S Vosler
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
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Are opioids necessary in post sinus surgery care? Curr Opin Otolaryngol Head Neck Surg 2020; 29:27-30. [PMID: 33337609 DOI: 10.1097/moo.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of the review is to review the recent literature on the use of opioids in post sinus surgery care. RECENT FINDINGS Research regarding the use of opioids in post sinus surgery over the past two years support previous thinking that there is an overprescription of opioids for an operation which is not particularly painful, resulting in the potential for narcotic abuse and misuse. SUMMARY Large randomized controlled trials with detailed pain recording scoring systems are needed to assess the opioid requirements - if any - after sinus surgery.
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