Reducing opioid use in post-operative otolaryngology patients: A quality improvement project

Patient Satisfaction with Nonopioid Postoperative Analgesia in Head and Neck Surgery: A Prospective Randomized Trial

OBJECTIVE

To evaluate patients' satisfaction with opioid versus opioid-sparing postoperative analgesia in patients undergoing outpatient head and neck surgery.

STUDY DESIGN

Prospective randomized trial.

SETTING

Tertiary care academic hospital.

METHODS

Adult patients undergoing outpatient head and neck surgery were randomly assigned to 1 of 3 analgesic regimens. First- and second-line medications were the following by group (1) Hydrocodone-acetaminophen with ibuprofen, (2) ibuprofen with hydrocodone-acetaminophen, and (3) ibuprofen with acetaminophen. Preoperative counseling was provided to patients regarding expected pain and proper medication use. Postoperative questionnaires were administered to assess satisfaction.

RESULTS

One hundred three patients were enrolled in the study (mean age, 56.5 years; women, 75 [73%]). The mean satisfaction score with the pain regimen assigned was similar between the 3 groups (scale 0-10, [7.7, 8.3, 8.5, P = .46]). A similar percentage of patients in each group reported that surgery was more painful than anticipated (25%, 32%, 26%, P = .978), and a similar percentage of patients reported willingness to utilize the same analgesic regimen following future surgeries (75%, 83%, 76%, P = .682). Additional questions evaluating the side effect profile, maximum and minimum pain scores, and difficulty of recovery were not statistically different between the 3 groups.

CONCLUSION

In the postoperative population for outpatient head and neck surgeries, there was no significant difference in patient satisfaction and pain control between the opioid and nonopioid arms. Providers should discuss opioid-sparing regimens preoperatively with patients and describe them as effective in providing adequate pain control without a significant impact on patient's perception of care.

Opioid-Sparing Pain Control after Rhinoplasty: Updated Review of the Literature

Rhinoplasty is one of the most performed elective surgeries, and given the opioid crisis, increasing research and studies are focused on successful pain control with multimodality opioid-sparing techniques, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin. Although limiting overuse of opioids is critical, this cannot be at the expense of inadequate pain control, particularly as insufficient pain control can be correlated with patient dissatisfaction and the postoperative experience in elective surgery. There is likely significant opioid overprescription, as patients often report taking less than 50% of their prescribed opioids. Furthermore, excess opioids provide opportunities for misuse and opioid diversion if not disposed of properly. To optimize postoperative pain control and minimize opioid requirements, interventions must occur at the preoperative, intraoperative, and postoperative time points. Preoperative counseling is imperative to set expectations for pain and to screen for predisposing factors for opioid misuse. Intraoperatively, use of local nerve blocks and long-acting analgesia in conjunction with modified surgical techniques can lead to prolonged pain control. Postoperatively, pain should be managed with a multimodal approach, incorporating acetaminophen, NSAIDs, and potentially gabapentin with opioids reserved for rescue analgesia. Rhinoplasty represents a category of short-stay, low/medium pain, and elective procedures highly susceptible to overprescription and consequently, are readily amenable to opioid minimization through standardized perioperative interventions. Recent literature on regimens and interventions to help limit opioids after rhinoplasty are reviewed and discussed here.

Assessing Impact: Implementing an Opioid Prescription Protocol in Otolaryngology

OBJECTIVE

A lack of guidance for pain control after otolaryngology surgery can lead to overprescription of opioids. We implemented a postoperative site-specific opioid prescription protocol and analyzed the impact on opioid prescriptions.

METHODS

This is a retrospective cohort study. A postoperative opioid prescription protocol was implemented within our otolaryngology department at a tertiary academic medical center on January 1, 2020. Retrospective chart review was completed for all patients undergoing otolaryngology surgery from November 1, 2019, to February 29, 2020 (2 months before and after initiation of intervention; n = 1070). The primary outcome was change in the amount of opioid prescribed for the preintervention and postintervention cohorts. Unplanned contact related to pain and opioid refills were tracked to assess pain control.

RESULTS

A total of 940 cases were included; adult and pediatric data were analyzed separately. There were 489 pediatric cases, 250 preintervention and 239 postintervention. There was a significant decrease in the amount of opioid prescribed per pediatric patient in the postintervention cohort (2.7 versus 0.32 morphine milligram equivalents, P = 0.02), and 99% of patients were not prescribed opioids at all. There was no significant change in unplanned contact, and no refills were required. There were 451 adult cases, 200 preintervention and 251 postintervention. There was no statistically significant decrease in the amount of opioid prescribed per adult patient (56.8 versus 51.7 morphine milligram equivalents, P = 0.23). There was no significant increase in unplanned contact or refills.

CONCLUSIONS

A postoperative opioid prescribing protocol can reduce the amount of opioid prescribed without increasing unplanned contact or opioid refills.

Age-Dependent Reduction in the Expression Levels of Genes Involved in Progressive Myoclonus Epilepsy Correlates with Increased Neuroinflammation and Seizure Susceptibility in Mouse Models

Brain aging is characterized by a gradual decline in cellular homeostatic processes, thereby losing the ability to respond to physiological stress. At the anatomical level, the aged brain is characterized by degenerating neurons, proteinaceous plaques and tangles, intracellular deposition of glycogen, and elevated neuroinflammation. Intriguingly, such age-associated changes are also seen in neurodegenerative disorders suggesting that an accelerated aging process could be one of the contributory factors for the disease phenotype. Amongst these, the genetic forms of progressive myoclonus epilepsy (PME), resulting from loss-of-function mutations in genes, manifest symptoms that are common to age-associated disorders, and genes mutated in PME are involved in the cellular homeostatic processes. Intriguingly, the incidence and/or onset of epileptic seizures are known to increase with age, suggesting that physiological changes in the aged brain might contribute to increased susceptibility to seizures. We, therefore, hypothesized that the expression level of genes implicated in PME might decrease with age, thereby leading to a compromised neuronal response towards physiological stress and hence neuroinflammation in the aging brain. Using mice models, we demonstrate here that the expression level of PME genes shows an inverse correlation with age, neuroinflammation, and compromised heat shock response. We further show that the pharmacological suppression of neuroinflammation ameliorates seizure susceptibility in aged animals as well as in animal models for a PME. Taken together, our results indicate a functional role for the PME genes in normal brain aging and that neuroinflammation could be a major contributory player in susceptibility to seizures.

Association of a Multimodal Intervention With Decreased Opioid Prescribing After Neck Dissection for Malignant Thyroid Disease With Short Hospital Stay

Importance

Prescribing practices for opioid medication after thyroid surgery have been well-studied and established; however, the need for pain management with opioid medication following lateral neck dissection for malignant thyroid disease with a short hospital stay has not been established.

Objective

To evaluate a multimodal opioid reduction intervention and its association with a decrease in prescribing of opioid medication at hospital discharge for patients after a lateral neck dissection for thyroid cancer.

Design, Setting, and Participants

This was a retrospective cohort study of patients treated from 2011 to 2021 by a tertiary academic institution that performs a high volume of thyroid cancer surgeries annually. We evaluated the electronic health records of 417 patients who had undergone lateral neck dissection for malignant thyroid disease from June 1, 2011, to June 30, 2021, and had a short hospital stay (≤3 days). Patients with longer stays (>3 days) or additional surgical procedures were excluded. Group 1 comprised patients who underwent a neck dissection before the intervention; and group 2, those who underwent the procedure after implementation of the intervention.

Intervention

A multimodal intervention composed of 3 components to reduce opioid prescribing at hospital discharge home after neck dissection for malignant thyroid disease with a short hospital stay.

Main Outcomes and Measures

The primary outcome was the quantity of opioid medication prescribed in the postoperative period, measured as oral morphine milliequivalents (MME). The eta-squared effect size (η2ES) metric was used to determine the association of the intervention with a reduction in the MME quantities of opioid medication administered to inpatients and prescribed at discharge. An estimated need for opioids was established for the average patient undergoing lateral neck dissection for thyroid cancer based on the upper range of prescribing after intervention. The data were analyzed from January to March 2022.

Results

The total study population was 417 patients: group 1 with 171 patients (mean [SD] age , 47.1 [15.6] years; 104 [61%] women; 144 [84%] non-Hispanic White) and group 2 with 246 patients (mean [SD] age , 46.2 [17.4] years; 146 [60%] women; 206 [83.7%] non-Hispanic White). The median MME prescribed at discharge for group 1 per patient was 225 MME compared with 0 MME for group 2, a large effect-size difference. There was a moderate association between the dose amount administered to an inpatient and the prescription dose they received at discharge (r, 0.33). Multiple linear regression analysis of sex, age, race and ethnicity, extent of surgery, and opioid reduction intervention showed that the intervention had a large clinically meaningful association with decreasing opioid prescriptions and dosage amounts at discharge (η2ES, 0.26; 95% CI, 0.19-0.33).

Conclusions and Relevance

The findings of this retrospective cohort study suggest that patients undergoing lateral neck dissections for thyroid cancer with short hospitalization needed very small amounts, if any, postoperative opioid medication for pain management. Adequate postoperative pain control was achieved using nonopioid interventions. Implementing an intervention to decrease the quantity of unnecessarily prescribed opioid medications during hospital discharge may help to reduce the risk of opioid addiction and overdose in patients after surgery.