Patient Education Reduces Opioid Prescribing After Neck Surgery

A new study suggests that patients undergoing thyroid and parathyroid surgery need little opioid treatment postoperatively if they receive preoperative patient education. The study of opioid prescribing practice and need for opioids after thyroidectomy and parathyroidectomy at Oregon Health and Sciences University (OHSU) was published in JAMA Otolaryngology-Head & Neck Surgery.

It describes an effort by some surgeons at OHSU to consciously reduce opioid medication in the wake of increased knowledge about opioid substance use disorder. It notes that the rate of drug overdose deaths increased from 6.1 per 100,000 standard population in 1999 to 16.3 per 100,000 in 2015, with an overall mean increase of 5.5% per year. According to the CDC, approximately 64,000 died in 2016 due to opioid overdose.

The authors write that, “More recently awareness of this epidemic and recognition of the medical community’s inadvertent contribution to the problem with previously accepted standard opioid prescribing practices have increased. From 2006 to 2016, the mean duration of opioid prescribed increased from 13.3 to 18.1 days per prescription, an overall 35.7% increase.”

This retrospective cohort study included 1788 opioid-naive patients who underwent thyroid and parathyroid surgery from January 1, 2012, through December 31, 2017. Patients with long-term opioid treatment and those who underwent other head and neck procedures or robotic thyroidectomy were excluded.

For analysis, 1765 procedures were available (723 parathyroidectomy, 400 hemithyroidectomy, and 642 total thyroidectomy).

The data was split into 2 timeframes to reflect different prescribing practices. Group 1 was defined as the period between January 1, 2012, to September 30, 2016, and group 2, or the current group, was defined as October 31, 2016, to December 31, 2017.

The effort to reduce opioid prescribing included preoperative patient counselling regarding pain management, multimodality nonopioid pain management, and work with nursing staff on assessing pain based on functional status (rather than a 1- to 10-point scale) and avoiding opioid administration when possible.

Patients were also told what to expect after surgery and how pain would be managed. They were also told that opioids could cause nausea and vomiting, which would not be good for a neck incision, and that soreness and discomfort would likely be treated with ice packs, ibuprofen, or acetaminophen, and that it would be unlikely they would need more relief than that.

The quantity of opioids prescribed in recovery if the patient was discharged the same day, or on the floor if admitted overnight, was generally used to determine the quantity of opioids to be prescribed on discharge. Researchers looked at the quantity of prescribed opioids in morphine milligram equivalents (MME) as well as for opioids refilled.

Of the 1702 patients, 80% were female [n = 1361] with a mean age of 51.2 years. A total of 1765 procedures were included in the analysis.

For parathyroidectomy, the mean (SD) opioid quantity prescribed was 176.20 (86.66) MME in group 1 versus 80.08 (74.43) MME in group 2 (effect size, 1.139).

• For hemithyroidectomy, 204.65 (112.24) MME in group 1 versus 112.24 (102.31) MME in group 2 (effect size, 0.842).
• For total thyroidectomy, 214.87 (161.09) MME for group 1 versus 102.29 (87.72) MME for group 2 (effect size, 0.754).
• In the last quarter of 2017, the numbers of patients discharged without any opioid prescription were 15 of 26 (57.5%) for parathyroidectomy, 12 of 32 (37.5%) for hemithyroidectomy, and 9 of 27 (33.3%) for total thyroidectomy.

Patient calls requesting pain medications for group 2 were similar or fewer, depending on the procedure. Those who were prescribed less than 75 MME postoperatively did not call for additional opioid prescriptions.

Researchers noticed a lot of variability in patterns of opioid prescribing. They said that could be due to the different experience levels of the doctor writing the prescription or default settings of the electronic health record.

One limitation of the study is that it only captured the prescribed dose of opioids and not the actual quantity of opioid consumed by patients at home.

Reference

Shindo M, Lim J, Leon E, Moneta L, Li R, Quintinalla-Diek L. Opioid prescribing practice and needs in thyroid and parathyroid surgery [published online October 25, 2018]. JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2018.2427.