Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns

Militsakh, Oleg; Lydiatt, William M.; Lydiatt, Daniel D.; Interval, Erik T.; Lindau, Robert; Coughlin, Andrew; Panwar, Aru

doi:10.1001/jamaoto.2018.0987

Cited by 68 publications

(62 citation statements)

References 15 publications

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“…Emerging studies support the use of multimodal analgesia following thyroid and parathyroid procedures. Militskah et al reported that it provides greater satisfaction scores than opioids alone . Shindo et al reported that multimodal analgesia reduced the total MME prescribed for both thyroidectomy (215 to 102) and parathyroidectomy (176 to 80) …”

Section: Discussionmentioning

confidence: 99%

“…Multiple studies report multimodal analgesia to be effective in reducing opioid consumption and managing pain. These regimens commonly utilize acetaminophen staggered with a nonsteroidal anti‐inflammatory drug (NSAID)/cyclooxygenase‐2 (COX‐2) inhibitor and/or gabapentin . Concerns regarding increased risk of bleeding from NSAIDs/COX‐2 inhibitors have not been substantiated by studies thus far .…”

Section: Discussionmentioning

confidence: 99%

“…These regimens commonly utilize acetaminophen staggered with a nonsteroidal anti-inflammatory drug (NSAID)/cyclooxygenase-2 (COX-2) inhibitor and/or gabapentin. 9,13,16,21 Concerns regarding increased risk of bleeding from NSAIDs/COX-2 inhibitors have not been substantiated by studies thus far. 21,25,26 Furthermore, some studies report NSAIDs to provide analgesia equivalent to opioids.…”

Section: Reducing Opioid Usementioning

confidence: 99%

“…9,13,16,21 Concerns regarding increased risk of bleeding from NSAIDs/COX-2 inhibitors have not been substantiated by studies thus far. 21,25,26 Furthermore, some studies report NSAIDs to provide analgesia equivalent to opioids. 24,26,27 Gabapentin, which is commonly used, only decreased subjective pain.…”

Section: Reducing Opioid Usementioning

confidence: 99%

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Postoperative opioid‐prescribing practices in otolaryngology: A multiphasic study

Dang

Duffy

et al. 2019

The Laryngoscope

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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

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Reducing Opioid Usementioning

confidence: 99%

Section: Reducing Opioid Usementioning

confidence: 99%

See 2 more Smart Citations

Postoperative opioid‐prescribing practices in otolaryngology: A multiphasic study

Dang

Duffy

et al. 2019

The Laryngoscope

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“…In response to this, many surgical subspecialties have tried to standardize prescribing practices and develop perioperative protocols for routine surgical procedures to guide prescribers. Otolaryngology has been no exception, and a quick review of the literature can find a number of articles reporting prescribing practices, alternate nonopioid regimens, and surveys of prescribers in all age groups and subspecialties . Despite this, there is no consensus on postoperative pain management for routine otolaryngology procedures.…”

Section: Introductionmentioning

confidence: 99%

Impact of perioperative pain management protocol on opioid prescribing patterns

et al. 2019

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Objectives/Hypothesis: The objective of this study was to demonstrate the impact of preoperative education, patient risk stratification, and a postoperative pain management protocol for common head and neck procedures on opioid prescribing patterns and postoperative pain reporting.Study Design: Retrospective cohort study. Methods: A postoperative pain management protocol was developed and implemented for patients undergoing head and neck surgical procedures. Medical charts were queried and postoperative patient satisfaction surveys were administered. Opioid prescribing patterns were evaluated in cohorts of patients undergoing procedures with anticipated mild pain (e.g., thyroidectomy, parotidectomy, lymph node biopsy) before and after the implementation of the protocol. Postoperative patient surveys were analyzed in the postimplementation group.Results: A total of 302 patients were included for analysis. One hundred fifty-four patients and 148 patients underwent surgery before and after the implementation of the protocol, respectively. There was a decreased incidence of oxycodonecontaining prescriptions (83% to 26%), and tramadol became the most common discharge medication (70%). There was a significant decrease in the total number of pills prescribed after the implementation of the protocol (34.71 to 25.36, P < .001). Ninety percent of patients reported high satisfaction (≥8) with pain management.Conclusions: This study shows that a comprehensive pain management protocol can significantly reduce the amount and potency of opioid pain medication prescribed after head and neck procedures while maintaining high patient satisfaction.

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Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction

Eggerstedt

Stenson

Ramirez

et al. 2019

JAMA Facial Plast Surg

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IMPORTANCEAn increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia.OBJECTIVE To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively.INTERVENTIONS Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed.MAIN OUTCOMES AND MEASURES Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia.RESULTS A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001). CONCLUSIONS AND RELEVANCEThe findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced.LEVEL OF EVIDENCE 3.

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Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns

Cited by 68 publications

References 15 publications

Postoperative opioid‐prescribing practices in otolaryngology: A multiphasic study

Postoperative opioid‐prescribing practices in otolaryngology: A multiphasic study

Impact of perioperative pain management protocol on opioid prescribing patterns

Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction

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