Prescription and Usage Pattern of Opioids after Thyroid and Parathyroid Surgery

The effectiveness of neck stretching exercises in alleviating neck pain and self-reported disability after thyroidectomy: A systematic review and meta-analysis of clinical trials

Thyroidectomy can lead to significant challenges such as neck pain, disability, and limited range of motion. Therefore, our objective is to conduct a systematic review and meta-analysis of clinical trials to investigate the clinical effectiveness of neck stretching exercises in alleviating neck pain and self-reported disability immediately after thyroidectomy. We systematically searched PubMed, CENTRAL, Scopus, and Web of Science from inception until July 28th, 2023. We assessed the selected trials for the risk of bias using both the RoB-2 and ROBINS-I tools. Our specific outcomes were the severity of neck pain and self-reported disability after thyroidectomy. The results were synthesized using risk ratio (RR) and standardized mean differences (SMD) with 95% confidence intervals (CI) in a random-effects model using Stata software. Nine clinical trials, comprising five randomized and four non-randomized trials, were included, with a total of 1026 patients. Neck stretching exercises were significantly associated with improved mean pain scores both after 1 week (n = 625 patients, SMD = -2.43, 95% CI [-4.65, -0.22], p = 0.03, I2 = 98%) and 1 month (n = 545 patients, SMD = -4.11, 95% CI [-8.12, -0.11], p = 0.04, I2 = 99%). Similarly, neck stretching exercises were significantly associated with improved mean self-reported disability scores both after 1 week (n = 298 patients, SMD = -0.70, 95% CI [-1.36, -0.04], p = 0.04, I2 = 87%) and 1 month (n = 298 patients, SMD = -0.42, 95% CI [-0.65, -0.19], p = 0.0004, I2 = 0%). The pooled analysis showed heterogeneity (chi-square p < 0.01, I2 > 80%), except for the mean self-reported neck disability score after 1 month, which showed homogeneity (chi-square p > 0.01, I2 = 0%). This systematic review and meta-analysis, involving 1026 patients, revealed the potential benefits of neck stretching exercises in alleviating neck pain and self-reported disability after thyroidectomy. However, further research is required to address methodological limitations, evaluate long-term outcomes, investigate potential moderators (i.e., the duration or intensity of the exercise program), and explore patients' analgesic consumption.

Chronic Opioid Prescribing After Common Otolaryngology Procedures in Adults

OBJECTIVE

(1) Describe short and long-term opioid prescribing patterns and variation after common otolaryngologic procedures and (2) assess risk factors for chronic opioid use in this cohort.

STUDY DESIGN

Retrospective cohort.

SETTING

Optum's deidentified Integrated Claims-Clinical data set.

METHODS

An adult cohort of patients undergoing common otolaryngology procedures from 2010 to 2017 was identified. Associations between procedure and other covariates with any initial opioid prescription and continuous opioid prescriptions were assessed with multivariable modeling. Opioid use was defined as continuous if a new prescription was filled within 30 days of the previous prescription. A time-to-event analysis assessed continuous prescriptions from the index procedure to end of the last continuous opioid prescription.

RESULTS

Among a cohort of 19,819 patients undergoing predominately laryngoscopy procedures (12,721, 64.2%), 2585 (13.0%) received an opioid prescription with variation in receiving a prescription, daily dose, and total initially prescribed dose varying by procedure, patient demographics, provider characteristics, and facility type. Opioids were prescribed most frequently after tonsillectomy (45.4%) and least frequently after laryngoscopy with interventions (3.9%), which persisted in the multivariable models. Overall rates of continuous use at 180 and 360 days were 0.48% and 0.27%, respectively. Among patients receiving an initial opioid prescription, maintaining continuous prescriptions was associated with tonsillectomy procedures, age (adjusted hazard ratio [aHR]: 0.997 per year, 95% confidence interval [CI]: 0.993-0.999), opioid prescriptions 6 months preprocedure (aHR: 0.42, 95% CI: 0.37-0.47), and nonotolaryngology initial prescribers (aHRs: <1, P < .05).

CONCLUSION

There is substantial variation in initial prescribing practices and continuous opioid prescriptions after common Otolaryngology procedures, but the overall rate of maintaining a continuous prescription starting after these procedures is very low.

LEVEL OF EVIDENCE

Level 3.

Rate and predictors of postoperative opioid use and high opioid exposure after surgery in New Zealand: a retrospective study

BACKGROUND

Although excessive opioid use is a significant global health issue, there is a lack of literature on the prescribing patterns for postoperative opioid use and exposure after discharge among surgical patients. This study aimed to examine the rate and predictors of opioid dispensing and high opioid exposure after hospital discharge from surgery in New Zealand (NZ) between January 2007 to December 2019.

METHODS

This is a retrospective population-based cohort study inclusive of all ages and surgical specialties. Data were obtained from the NZ Ministry of Health's national health databases.

RESULTS

1 781 059 patients were included in the study and 20.9% (n = 371 882) of surgical patients received opioids within 7 days after hospital discharge. From those who were dispensed with opioids after hospital discharge, 36.6% (n = 134 646) had high opioid exposure. Orthopaedic surgery (AOR 6.97; 95% CI 6.82-7.13) and history of opioid use (AOR 3.18; 95% CI 2.86-3.53) increased the odds of postoperative opioid dispensing and high opioid exposure respectively. Severe multi-morbidity burden (AOR 0.76; 95% CI 0.73-0.78) and alcohol misuse (AOR 0.84; 95% CI 0.77-0.93) lowered the odds of postoperative opioid dispensing and high opioid exposure respectively.

CONCLUSIONS

Our findings suggest a concerning rate of high opioid exposure among surgical patients after discharge. The predictors for postoperative opioid dispensing and high opioid exposure identified in our study provide insight into opioid prescribing patterns in NZ and inform future postoperative pain management.

Patterns of Prescribing Postoperative Analgesic Medication After Thyroid Surgery: A Retrospective Cohort Study

Background

Mild-to-moderate postoperative pain is common after surgical procedures of the thyroid. Opioid analgesics have been commonly prescribed in such cases, but their use has been debated owing to concerns regarding the addictive nature of opioids. Recently, experts from the Endocrine Surgery Section of the American Head and Neck Society released a consensus document to limit the use of opioids as the first-line pain control medication after head and neck or endocrine procedures. However, differences in pain management prescriptions have been noted in many settings. This study aims to assess the post-thyroid surgery pain control medication prescription practices of head and neck and endocrine surgeons.

Methods

This study retrospectively reviewed the charts of 105 adult patients who underwent thyroid surgery (total thyroidectomy, thyroid lobectomy, or subtotal thyroidectomy) by head and neck or endocrine surgeons. The type of prescribed pain medication at hospital discharge postoperatively was then retrieved from each patient's discharge medication list. Descriptive statistics mean, standard deviations, frequencies, and percentages were computed, while the Chi-square test was applied to measure the significant differences among variables at a 5.00% significant level.

Results

An outpatient oral opioid, in the form combining paracetamol and codeine, was prescribed for 62 (59%) patients, whereas 43 (41%) were discharged on paracetamol only.

Conclusion

The use of opioids is the practice pattern for pain management among some head and neck or endocrine surgeons despite emerging evidence that supports the use of non-opioid and other alternative analgesic strategies in outpatient thyroid and parathyroid surgery. Further research and quality improvement interventions should be geared towards leading all health professionals to appropriate prescription practices to improve patient safety and reduce unnecessary opioid prescriptions.

Remote smart pill cap monitoring of post-surgical pain management in thyroid and parathyroid surgery

BACKGROUND

With recent efforts to decrease opioid use following surgery, this study aims to answer: what pain regimen do patients follow at home? Is it controlling pain?

METHODS

This is a prospective, pilot study of thyroid and parathyroid surgery patients. Patients were prescribed acetaminophen, ibuprofen, and tramadol dispensed in smart pill (Pillsy) bottles that record "events" corresponding to medication use. Patients received messages querying their current pain level. Patients were compared to historical controls.

RESULTS

26 patients were in the Pillsy group and 30 in the control group. In the Pillsy group, pain scores averaged 3.67 out of 10 in the first 24 h after surgery and decreased each day. Patients took an average of 6.45 doses of acetaminophen, 6.64 doses of ibuprofen, and 1.82 doses of tramadol in the first week.

CONCLUSIONS

Pain scores are highest in the first 24 h after surgery and decrease thereafter. This acceptable level of pain can be achieved with non-opioid medications.

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.

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.

Impact of Liposomal Bupivacaine on Post-Operative Pain and Opioid Usage in Thyroidectomy

OBJECTIVES

Opioid analgesia has been integral in post-operative pain control for decades. The over-prescription of opioids, commonly in the surgical patient, has contributed to the current opioid epidemic. Liposomal bupivacaine (LB), a long-acting analgesia formulation, has demonstrated decreased post-operative pain and opioid requirements in patients treated across multiple surgical subspecialties. The aims of this retrospective study are to assess post-operative pain and opioid use in patients who received LB at the time of thyroidectomy.

METHODS

A cohort-matched retrospective review of patients who underwent thyroidectomy by 2 surgeons between January 2010 and December 2019 was performed. Patients were divided into those that received LB intraoperatively and those that did not. Statistical analyses were performed using the Chi-square or Fisher's exact test, and 2-sample T-test or Wilcoxon rank sum test.

RESULTS

Of the 201 patients included in this study, 113 patients received LB and 88 did not. Patients who received LB had a lower median visual analog scale (VAS) pain score (2 vs 3, P = .2252), lower maximum VAS pain score (6 vs 7, P = .0898), were less likely to require opioid medications (73.5% vs 85.2%, P = .0434), and had a lower percentage of daily morphine milligram equivalent value ≥45 (89.8% vs 95.3%, P = .1581) during the post-operative period when compared to those that did not.

CONCLUSION

This study suggests a role for incisional infiltration with LB for post-operative pain management in patients undergoing transcervical thyroidectomy. We report reduced post-operative pain scores and opioid analgesia requirements in patients who received LB.

The effect of a statewide prescription drug monitoring program on opioid prescribing patterns

PURPOSE

Determine whether opioid prescribing patterns have changed as a result of implementation of a prescription drug monitoring program (PDMP) in the state of Massachusetts.

MATERIALS AND METHODS

A multicentered retrospective study was performed including patients who received tonsillectomy, parotidectomy, thyroidectomy or direct laryngoscopy and biopsy with or without rigid esophagoscopy and/or rigid bronchoscopy at Lahey Hospital and Medical Center (Burlington, MA) or Boston Medical Center (Boston, MA). Opioid prescribing patterns were compared for the 12 months prior to implementation of the Massachusetts Prescription Awareness Tool (MassPAT) to 36 months of prescribing patterns post implementation. Quantity of opioids prescribed was based on morphine milligram equivalents (MME). Continuous variables were compared using analysis of variance (ANOVA) while categorical variables were compared using chi-squared test or Fisher's exact test. Multivariate analysis was performed using linear regression.

RESULTS

A total of 2281 patients were included in the study. There was a significant association in mean overall MME prescribed comparing pre-MassPAT and post-MassPAT data [tonsillectomy: 635.9 ± 175.6 vs 463.3 ± 177.7 (p < 0.0001), parotidectomy: 250.4 ± 71.33 vs 169.8 ± 79.26 (p < 0.0001), thyroidectomy: 186.2 ± 81.14 vs 118.3 ± 88.79 (p < 0.0001), direct laryngoscopy with biopsy: 308.3 ± 246.9 vs 308.3 ± 246.9 (p = 0.0201)]. There was also a significant association between length of opioid prescription (days) and implementation of MassPAT, but there was no significant difference in the percent of patients requiring refills pre- MassPAT and post-MassPAT.

CONCLUSION

This study demonstrates that prescribers have been able to significantly decrease the amount of opioids prescribed for tonsillectomy, parotidectomy, thyroidectomy, and direct laryngoscopy and biopsy and patients have not required additional opioid refills.

Perioperative pain management for thyroid and parathyroid surgery: A systematic review

INTRODUCTION

A growing body of evidence suggests that surgeons have historically over-prescribed opioid pain medications following thyroid and parathyroid surgery, thereby potentially contributing to the current US opioid epidemic. We reviewed the evidence supporting multimodal methods of pain control after cervical endocrine surgery.

METHODS

Fifty-one randomized clinical trials, 9 prospective cohort studies, 7 retrospective studies/reviews, and 1 survey regarding pain management for cervical endocrine surgery were include.

RESULTS

Most studies reported in-hospital pain scores and opioid consumption. Data on pain scores following discharge were limited. In several studies, the interventional dose was much greater than what is commonly used clinically.

CONCLUSION

Several evidence-based, non-opioid interventions can be incorporated into a standardized pain management protocol following cervical endocrine surgery. Little is known regarding the effects of these interventions on post-discharge pain scores and patient quality of life during recovery.

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

PURPOSE

In opioid-naive patients, many low-risk surgical procedures are associated with an increased risk of chronic opioid use. The goal of this quality improvement project was to reduce the amount of opioid prescriptions after commonly performed surgeries in otolaryngology.

MATERIALS AND METHODS

Pre-intervention opioid prescribing state was measured using anonymous provider and patient surveys, as well as pharmacy provider prescription data. Next, this information was used to develop an opioid prescription protocol that both standardized opioid prescribing practices and encouraged multimodal analgesia following routine surgery. Finally, post-intervention data were gathered and compared to pre-intervention data to assess changes in prescribing patterns.

RESULTS

By patient survey, the worst pain and average pain after surgery (scale of 1-10) were unchanged after the intervention (5.1 to 4.8, p = 0.52; 4.1 to 3.6, p = 0.35, respectively). Post-intervention, 41% of patients reported receiving no opiates, whereas pre-intervention 100% of patients surveyed received opiates. The amount of ibuprofen and acetaminophen prescribed post-intervention increased 113% and 71%, respectively. By survey, the average number of opioid doses decreased from 24.0 ± 7.0 to 18.4 ± 6.6 (p = 0.018).

CONCLUSIONS

The implementation of a standardized physician opioid prescription protocol did not affect patient pain perceptions, resulted in an increase in multimodal analgesia prescription, and increased provider awareness of opioid over prescription.

Postoperative Opioid-Prescribing Practices in Nasal Surgery: A Prospective Study

Importance: There has been a greater awareness of the opioid epidemic. Studies are needed to better characterize opioid usage after outpatient nasal surgery. Objective: Provide data to guide prescription management for nasal procedures and investigate opioid prescription and subsequent consumption, with the aim of offering analysis to build evidence-based guidelines for postoperative pain management. Design, Setting, and Participants: In this prospective single-center study, morphine milligram equivalents (MME) consumption and pain scores were collected in 69 patients who underwent nasal surgery. Main Measures and Outcomes: Patient demographics, MME use, and pain scores were examined. MME use was compared with patient demographics, surgical procedure type, and postoperative pain scores. Results: In total, 3302 MME were prescribed: 2012 MME (61%) were used, leaving 1290 MME (39%). Patients were prescribed a total average of 47.8 ± 24.0 MME. Four (6%) patients required a second prescription. History of opioid use, benzodiazepine use, and obesity were negative predictors of opioid consumption (p ≤ 0.001). Conclusion and Relevance: Assessing opioid consumption for nasal procedures will guide prescribing practices. Our results indicate that prescription practices can likely be down titrated in patients with a history of certain medication consumption.

Patient-Reported Pain and Opioid Use After Ambulatory Head and Neck Surgery

Objective

The main objective of this study was to quantify daily pain and opioid use in patients after hemithyroidectomy and cervical lymph node biopsy (CLNB). The secondary objective was to identify factors associated with decreased pain and opioid use.

Study Design

Prospective cohort study from June 2017 to February 2019. Patients were given paper surveys to record daily postoperative opioid use and maximal pain on a visual analog scale.

Setting

Single institution (NewYork-Presbyterian/Weill Cornell Medical Center).

Methods

All adult patients undergoing hemithyroidectomy and CLNB by a single surgeon were consecutively selected for participation. Patients recorded daily pain and opioid analgesic use over a 2-week postoperative period.

Results

Of 33 patients enrolled, 29 (87.9%) returned a survey. Thirteen underwent CLNB, and 16 underwent hemithyroidectomy. Pain resolved after both procedures by the end of the 2-week period. CLNB patients used a median (interquartile range) of 15.0 (0-41.2) morphine milligram equivalents (MME), and 95% used 70 or fewer MME. Hemithyroidectomy patients used a median of 8.2 (4.5-13.9) MME, and 95% used 30 or fewer MME. Use of nonopioid analgesics was associated with a statistically significant decrease in pain (56.1 vs 171 visual analog scale, 95% confidence interval [CI] of Δ = [12.0 to 217.8]) and opioid use (12.2 vs 48.8 MME, 95% CI of Δ = [5.0 to 68.1 MME]) in CLNB but not in hemithyroidectomy.

Conclusion

Patients have low pain and opioid requirements after hemithyroidectomy and CLNB. Head and neck surgeons should evaluate their opioid-prescribing patterns for opportunities to safely decrease postoperative prescriptions.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement

BACKGROUND

This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.

METHODS

An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.

CONCLUSIONS

This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Opioid Prescribing Patterns After Head and Neck Surgery

OBJECTIVE

Postoperative prescription narcotics increase access to opioids and associated abuse among patients, family, and acquaintances. Judicious opioid stewardship is required. Best practice questions remain for larger head and neck surgeries. We aim to review opioid utilization patterns in an urban patient population to identify patients at risk for poor postoperative pain control.

STUDY DESIGN

Case series with planned chart review for patients undergoing head and neck surgery (2015-2018).

SETTING

Single urban hospital.

METHODS

Outcome measures included postoperative phone calls and emergency room visits as markers for inadequate pain control. Age, sex, race, body mass index (BMI), smoking status, comorbidities, prior narcotic filling behavior, surgery type, and duration were evaluated as potential risk factors for pain control. Chi-square and Wilcoxon tests were used for group comparisons.

RESULTS

In total, 215 patients met inclusion criteria: male (22%), white/Hispanic (47%), and African American (44%). Median BMI was 31.6 kg/m²; median age was 52 years. Surgeries included total thyroidectomy (41%), hemithyroidectomy (27%), and parathyroidectomy (15%). The 23-hour observation patients (n = 175, 81%) had a median of 20 morphine milligram equivalents (MMEs). Sixteen patients experienced inadequate pain control. Female sex (P = .03), younger age (P = .02), current smoker (P = .03), and higher inpatient MME (P = .006) were associated with inadequate pain control.

CONCLUSION

Female sex, younger age, smokers, and high inpatient opioid dose requirements are associated with inadequately controlled pain. These patients may benefit from additional education, earlier postoperative visits, and a more comprehensive nonopioid regimen.

The Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology Surgeries

OBJECTIVE

Determine whether opioid prescriber patterns have changed for tonsillectomy, parotidectomy, and thyroidectomy after implementation of the Massachusetts Prescription Awareness Tool (MassPAT).

STUDY DESIGN

Retrospective cohort study.

SETTING

Single-center tertiary care hospital.

METHODS

Patients were included if they received tonsillectomy, parotidectomy, or thyroid surgery at Lahey Hospital and Medical Center (Burlington, Massachusetts) between October 1, 2015, and October 1, 2019. Prescribing patterns were compared prior to implementation of MassPAT, October 1, 2015, to October 14, 2016, to postimplementation of MassPAT, October 15, 2016, to October 1, 2019. Quantity of opioids prescribed was described using total morphine milligram equivalents (MME). Data were analyzed using univariate analysis, multivariate analysis, and trend line using line of best fit.

RESULTS

A total of 737 subjects were included in the study. There was a downward trend in the quantity of opioids prescribed for all 3 surgeries during the study period. There was a significant difference in the quantity of opioids prescribed pre- and postimplementation of MassPAT for tonsillectomy (647.70 ± 218.50 MME vs 474.60 ± 185.90 MME, P < .001), parotidectomy (241.20 ± 57.66 MME vs 156.70 ± 72.99 MME, P < .001), and thyroidectomy (171.20 ± 93.77 MME vs 108.50 ± 63.84 MME, P < .001). There was also a decrease in the number of patients who did not receive opioids for thyroidectomy pre- and post-MassPAT (7.56% vs 24.14%).

CONCLUSION

We have demonstrated that there is an association with state drug monitoring programs and decrease in the amount of opioids prescribed for acute postoperative pain control for common otolaryngology surgeries.

Reducing Opioid Use in Endocrine Surgery Through Patient Education and Provider Prescribing Patterns

BACKGROUND

Postoperative opioid use can lead to dependence, contributing to the opioid epidemic in the United States. New persistent opioid use after minor surgeries occurs in 5.9% of patients. With increased documentation of persistent opioid use postoperatively, surgeons must pursue interventions to reduce opioid use perioperatively.

METHODS

We performed a prospective cohort study to assess the feasibility of a preoperative intervention via patient education or counseling and changes in provider prescribing patterns to reduce postoperative opioid use. We included adult patients undergoing thyroidectomy and parathyroidectomy from January 22, 2019 to February 28, 2019 at a tertiary referral, academic endocrine surgery practice. Surveys were administered to assess pain and patient satisfaction postoperatively. Prescription, demographic, and comorbidity data were collected from the electronic health record.

RESULTS

Sixty six patients (74.2% women, mean age 58.6 [SD 14.9] y) underwent thyroidectomy (n = 35), parathyroidectomy (n = 24), and other cervical endocrine operations (n = 7). All patients received a preoperative educational intervention in the form of a paper handout. 90.9% of patients were discharged with prescriptions for nonopioid pain medications, and 7.6% were given an opioid prescription on discharge. Among those who received an opioid prescription, the median quantity of opioids prescribed was 135 (IQR 120-150) oral morphine equivalents. On survey, four patients (6.1%) reported any postoperative opioid use, and 94.6% of patients expressed satisfaction with their preoperative education and postoperative pain management.

CONCLUSIONS

Clear and standardized education regarding postoperative pain management is feasible and associated with high patient satisfaction. Initiation of such education may support efforts to minimize unnecessary opioid prescriptions in the population undergoing endocrine surgery.

Evaluation of opioid prescription patterns among patients undergoing thyroid surgery

BACKGROUND

There is variability in opioid prescription patterns among surgeons performing thyroidectomy. Thus, the aim of this study is to evaluate opioid prescription rates and opioid use among hemithyroidectomy (HT) and total thyroidectomy (TT) patients.

DESIGN/METHOD

An electronic postoperative survey was distributed to assess opiate use among patients undergoing HT/TT. Groups were compared using t-tests, chi-square tests, and analysis of variance.

RESULTS

A total of 142 opiate naïve patients were included, of which 75 (52.8%) underwent HT and 67 (47.1%) underwent TT. The mean number of tablets prescribed was 21.3 (HT = 22.1, TT = 20.4; P = 0.3), with a mean of 14.1 tablets unused after surgery (HT = 13.2 tablets, TT = 15.0 tablets; P = 0.44). The mean morphine milligram equivalent (MME) prescribed was 150.1 mg (HT = 159.0 mg, TT = 140.2 mg; P = 0.3), with a mean of 98.2 MME unused after surgery (HT = 93.7 mg, TT = 103.2 mg; P = 0.6).

CONCLUSIONS

Opioids are overprescribed after thyroid surgery. Avoidance of overprescribing is vital in mitigating the current opioid crisis.

Objective Quantification of Opioid Usage After Thyroid Surgery

Introduction  It is well established that America is in the midst of an opioid crisis with 46 people dying every day from overdoses involving prescription opioids. In the last 2 years, multiple articles have been published indicating that the amount of opioid pain medication needed after discharge from thyroid and parathyroid surgery is low.

Objective  To objectively examine the amount of opioid pain medication required by patients in our practice after thyroid surgery.

Methods  Patients were given a standardized discharge prescription of 30 pills with a combination of 7.5 mg of hydrocodone and 325 mg of acetaminophen after thyroid surgery. They were asked to log the number of pills consumed per day and the level of pain per day using the Wong-Baker faces pain scale. We used in-office pill counts to ensure accuracy of the logs.

Results  While reaching a similar conclusion, the present study is the first to objectively examine the quantity of opioid pain medication consumed between postoperative discharge and office follow-up. Our study objectively demonstrates that 85% of patients consumed less than 75.0 morphine milligram equivalent (MME) after thyroid surgery using in-office pill counts.

Conclusion  Recent multimodality anesthesia research appears promising to dramatically reduce or even eliminate the need for opioid prescriptions upon postoperative discharge.

Perioperative Analgesia for Thyroid and Parathyroid Surgery: A Review of Current Practices

This article discusses the algorithms and published practice patterns on perioperative analgesia for thyroid and parathyroid surgery. This includes medications and techniques used for general anesthesia, local anesthesia including nerve block methods, and oral medication used for postoperative pain control. The authors also discuss multimodality pain control and the increased trend to reduce opioid analgesics without inadequate pain control or patient satisfaction.

Are narcotic pain medications necessary after discharge following thyroidectomy and parathyroidectomy?

BACKGROUND

The aim of this study was to determine whether patients undergoing thyroidectomy and parathyroidectomy have similar postoperative pain if managed with an opioid-sparing regimen versus an opioid-containing regimen. We hypothesized that an opioid-sparing regimen would provide equivalent analgesia.

METHODS

We performed a prospective, randomized trial (clinicaltrials.govNCT03640247) comparing non-narcotic and narcotic postoperative pain regimens after discharge. Patients ≥18 y undergoing thyroidectomy or parathyroidectomy were eligible for inclusion. Patients were excluded if they were taking a narcotic. Patients in the nonnarcotic arm of the study received acetaminophen, alternating with ibuprofen, and patients in the narcotic arm received the same medications plus a narcotic.

RESULTS

Of 126 patients, 64 patients were in the nonnarcotic group and 62 were in the narcotic group. The mean age was 54 ± 14 y, and 108 (86%) patients were female. Median pain scores were similar on postoperative day #0 (narcotic group 7 versus nonnarcotic group 7.5), postoperative day #1 (narcotic group 6 versus nonnarcotic group 6), postoperative day #2 (narcotic group 5 versus nonnarcotic group 5), postoperative day #3 (narcotic group 4 versus nonnarcotic group 4), postoperative day #4 (narcotic group 3 versus nonnarcotic 3) and postoperative day #5 (narcotic group 2.5 versus nonnarcotic group 2, all P > .1). A total of 31 (50%) patients in the narcotic group did not take a narcotic. A total of 8 (12.5%) patients in the nonnarcotic group and of 31 (50%) patients in the narcotic group took a median total of 2 narcotic tablets.

CONCLUSION

An opioid-sparing pain medication regimen provides effective analgesia for most patients after thyroidectomy and parathyroidectomy.

Multicenter study on the effect of nonsteroidal anti-inflammatory drugs on postoperative pain after endoscopic sinus and nasal surgery

BACKGROUND

The taboo of avoiding nonsteroidal anti-inflammatory drugs (NSAIDs) after functional endoscopic sinus surgery (FESS) has been waning. The impetus to reduce opioid prescriptions in view of the opioid epidemic led the authors to change their practices to include NSAIDs after sinus surgery. This study's aim was to analyze the differences between patients before and after we began recommending NSAIDs after FESS.

METHODS

A prospective cohort study was performed on patients undergoing FESS or other endoscopic nasal surgeries at 3 institutions, by 5 rhinologists and 1 facial plastic surgeon. Before introducing NSAIDs, all patients were given a prescription for hydrocodone-acetaminophen 5/325 mg and also recommended preferentially to use acetaminophen 325 mg. After the addition of NSAIDs, ibuprofen 200 mg and acetaminophen 325 mg were recommended preferentially, using the narcotic as a rescue medication. Patients kept a pain diary and medication log, and gave a visual analog scale (VAS) score for overall pain. Demographics, surgical variables, and comorbidities were also analyzed.

RESULTS

One hundred sixty-six total patients were recruited and had data that could be analyzed (65 without NSAIDs, 101 with NSAIDs). Overall, mean pain VAS score was 3.12 ± 1.95 for the non-NSAID group and 2.33 ± 2.30 for the NSAID group (p value = 0.006). The day with the highest mean pain was the first postoperative day. The mean number of total opioid pills taken was 6.94 ± 6.85 without NSAIDs vs 3.77 ± 4.56 with NSAIDs (p = 0.018). Age and gender were found to be the only consistently significant patient variables to affect pain. There were no bleeding complications.

CONCLUSION

NSAID use was introduced into the practices of 5 practicing rhinologists and 1 facial plastic surgeon. No bleeding complications were seen. Both pain and overall opioid usage were reduced significantly.

Postoperative Analgesic Requirement and Pain Perceptions after Nonaerodigestive Head and Neck Surgery

OBJECTIVES

Little data exist on associations between patient factors and postoperative analgesic requirement after head and neck (H&N) surgeries. Such information is important for optimizing postoperative care considering concerns regarding opioid misuse. We analyzed factors associated with narcotic use and pain perception following H&N surgery sparing the upper aerodigestive tract.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

From May to October 2017, data were collected for patients undergoing nonaerodigestive H&N procedures requiring hospitalization. Patients completed a preoperative survey querying chronic pain history, narcotic usage, and postoperative pain expectation. Demographics, surgical data, postoperative narcotic use defined by morphine milligram equivalents (MME), pain scores, and Overall Benefit of Analgesia Score (OBAS) were analyzed.

RESULTS

Seventy-six patients, 44 (57.9%) females and 32 (42.1%) males with a mean age of 54.0 years, met inclusion criteria. The most common procedures were parotidectomy (27.6%) and total thyroidectomy (19.7%). Average cumulative 24-hour postoperative MME and calculated MME per hospital day (MME/HD, cumulative MME for hospitalization divided by length of stay) were 40.5 ± 30.6 and 60.8 ± 60.1, respectively. Average pain score throughout the initial 24 hours after surgery was 3.7/10 ± 2.0. Female sex and prior chronic pain diagnosis were associated with higher OBAS after multivariate linear adjustments.

CONCLUSION

Postoperative narcotic requirement in nonaerodigestive H&N surgery is overall low. Female sex and prior chronic pain diagnosis may be associated with higher postoperative OBAS, a validated assessment of pain and opioid-related side effects. This study may serve as a comparison for future studies evaluating narcotic-sparing analgesia and pain perception in nonaerodigestive H&N surgery.

Postoperative opioid-prescribing practices in otolaryngology: A multiphasic study

OBJECTIVES

In otolaryngology, postoperative pain management lacks evidence-based guidelines. We designed a prospective, multiphasic study aimed to develop evidence-based guidelines for postoperative pain management within our institution. In this first phase of our project, we investigated opioid prescription and consumption as well as pain trends for common otolaryngologic procedures.

METHODS

Patients (n = 161) who underwent procedures between July 2018 and February 2019 were surveyed on their postoperative opioid usage and pain from day of discharge to first clinic visit. Opioid prescriptions were converted to standardized units of morphine milligram equivalents (MME). The procedures selected for analysis were parathyroidectomy/thyroidectomy, parotidectomy, sialendoscopy, and transoral robotic surgery resection (TORS).

RESULTS

In total, 19,748 MME were prescribed: 8,588 MME (43.5%) were used, leaving 11,159 MME (56.5%) unused. TORS average MME used: 221 ± 227; total MME unused: 38%. Sialendoscopy average MME used: 31 ± 46; total MME unused: 67%. Parathyroidectomy/thyroidectomy average MME used: 30 ± 37; total MME unused: 66%. Parotidectomy average MME used: 43 ± 53; total MME unused: 65%. Male gender, smoking (current and former), and psychiatric medication use were positive predictors of opioid consumption in postoperative patients (P < 0.001).

CONCLUSION

At our institution, over 50% of prescribed postoperative opioids went unused. This was most pronounced for nonmucosal surgeries. Postoperative pain management should account for this to minimize unnecessary opioid prescriptions. Based on our findings and review of current literature, we are in the process of developing prescribing recommendations to be implemented within our institution.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:659-665, 2020.

Postoperative Pain and Opioid Use After Thyroid and Parathyroid Surgery-A Pilot, Prospective SMS-Based Survey

BACKGROUND

New persistent opioid use has been identified following minor surgical procedures and may contribute to the national opioid epidemic. Prescription patterns vary and we have limited data on patient pain experiences in the outpatient setting. We devised a novel short messaging service survey to record pain scores and opioid use following outpatient thyroid or parathyroid surgery.

MATERIALS AND METHODS

Automated short messaging service was sent daily starting the evening of the operation until postoperative day (POD) 10. Pain was assessed on a 0-10 numeric pain rating scale and opioid use over the prior 24 h was queried.

RESULTS

A total of 1264 survey questions were sent with overall response rate of 84.3%. Fifty-three of 58 patients had a response rate >50% and were included in the final analysis. Average pain score was highest on POD1 at 3.2. Overall, 42.5% of patients utilized opioids on POD0, 55.6% on POD1, and steadily decreased to 7% by POD10. Overall, 34% of patients did not utilize any opioids postoperatively. Scaled total pain scores were higher in patients with thyroid surgery (23.5 versus 12.1, P = 0.02) and lower in those who reported alcohol use (14.9 versus 31.6, P < 0.02). Scaled total opioid days were lower in those aged >60 (1.5 versus 3.6, P < 0.01) and higher in those with active tobacco use (4.5 versus 2.3, P = 0.04). Pain scores correlated weakly with total opioid days (r = 0.32).

CONCLUSIONS

We demonstrate a novel approach of obtaining patient reported daily, prospective pain scores. This may help us understand patient pain and opioid use in the acute postoperative period especially following outpatient surgery.

A Randomized Single-Blinded Trial of Ibuprofen- versus Opioid-Based Primary Analgesic Therapy in Outpatient Otolaryngology Surgery

Objective

To compare the efficacy of pain control and opioid consumption between patients who receive opioid as primary analgesic therapy and those who receive ibuprofen.

Study Design

Prospective randomized trial.

Setting

Tertiary care academic hospital.

Subject and Methods

Adult patients undergoing outpatient otolaryngology surgery were assigned to take hydrocodone/acetaminophen or ibuprofen for postoperative analgesia. Patient-recorded pain scores and analgesic consumption were analyzed.

Results

Out of 185 recruits, 108 (58%) completed responses. Fifty-six patients (52%) received opioid medication for primary analgesic treatment versus 52 (48%) who received ibuprofen. There was no difference in reported pain scores between the treatment groups. Those who received ibuprofen as primary therapy reported a significantly lower consumption of opioid medication at 2.04 tablets/pills (95% CI, 0.9-3.1) versus 4.86 (3.6-6.1; P = .001). Based on multivariate analysis, male sex and older age exhibited lower reported pain scores, while older age and use of ibuprofen as primary therapy exhibited lower opioid requirements.

Conclusion

For postoperative pain management in outpatient otolaryngology procedures, ibuprofen as primary therapy can provide equally effective pain control as compared with hydrocodone/acetaminophen while decreasing overall opioid requirement. Prescription pill counts are further described to help guide physician practices in the era of an opioid epidemic.