Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients

Abstract

Postoperative opioid use has been linked to the subsequent development of opioid dependency. Multimodal analgesia (MMA) can reduce the use of opioids in the postoperative period, but MMA has not been well-studied after major head and neck surgery. Our goal is to explore the association between MMA and postoperative opioid use and pain control in patients undergoing major head and neck surgery. We performed a retrospective study in adult (age 18 years) patients undergoing primary head and neck cancer resection with free-flap reconstruction. All patients were treated using an established care pathway. The baseline group was treated between January 2015–December 2015 (n = 41), prior to the implementation of MMA, and were compared to an MMA-treated cohort treated between December 2017–June 2019 (n = 97). The primary outcome was the proportion of opioids prescribed and oral morphine equivalents (OMEs) consumed during the hospitalization. The secondary outcome was pain control. We found that the post-MMA group consumed fewer opioids in the postoperative period compared to the pre-MMA group. Prior to post-operative day (POD) 6, pain control was better in the post-MMA group; however, the pain control lines intersect on POD 6 and the pre-MMA group appeared to have better pain control from PODs 7–10. In conclusion, our data suggest MMA is an effective method of pain control and opioid reduction in patients undergoing surgery for head and neck cancer with free flap reconstruction. MMA use was associated with a significant decrease in the quantity of opioids consumed postoperatively. The MMA protocol was associated with improved pain management early in the postoperative course. Finally, the MMA protocol is a feasible method of pain control and may reduce the adverse side effects associated with opioid use.

From Pathways to Practice: Impact of Implementing Mobilization Recommendations in Head and Neck Cancer Surgery with Free Flap Reconstruction

“…The benefit of goal-directed fluid therapy may be marginal [37], but adequate pain control is expected to facilitate early mobilization. We have previously shown that the introduction of an opioid-sparing pain management protocol increased the proportion of patients with adequate pain control (pain rating below 4/10) by ~10% in the first 24 h after surgery [38]. Changes in pain management in our study could have contributed to compliance with the pathway recommendation, but it cannot account for the decrease in time to mobilization after the introduction of the new mobilization recommendation in February 2016 (Figure 1).…”

The Impact of Enhanced Recovery Pathways in Head and Neck Surgery: A Systematic Review

“…The findings of Clark, et al [10] support those of Kiong, et al [12] and Jandali, et al [11] in demonstrating lower post-operative peak pain scores (4.6 ± 3.6 vs. 6.5 ± 3.5 (p = 0.004)) and lower morphine milligram equivalents in the ERAS group in comparison to the non-ERAS cohort (6.0 ± 9.8 vs. 10.3 ± 10.8 (p = 0.010)). Hinther, et al [14] compared patients on a multi-modal analgesia (MMA) protocol with those on a 'pre-MMA' pathway. Average daily opioid consumption was lower in the MMA group (29.7 mg vs. 43.3 mg (p = 0.04)) and pain was managed more effectively for the first 6 days postoperatively using an MMA approach.…”

Pain Management in Oncology Patients Amidst the Opioid Epidemic: How To Minimize Non-Medical Opioid Use

“…6. Implement a multimodal approach, including specialist referral: consider referral of patients at high risk of substance abuse [53][54][55][56].…”