Keywords
thyroidectomy - opioid - postoperative pain - head and neck surgery - otolaryngology
Introduction
It is well established that America is in the midst of an opioid crisis. Forty-six
people die every day from overdoses involving prescription opioids.[1]
[2] It has been shown that short-term opioid use is associated with a higher likelihood
of long-term misuse. An excess of opioid analgesic prescription is associated with
diversion.[3]
Individuals misusing opioids often obtain them from family or friends, and opioids
are now considered a gateway drug to heroin.[4] Among new heroin users during 2000 to 2013, approximately 3 out of 4 report having
misused prescription opioids prior to using heroin.[3]
There is wide variation in postoperative prescribing practices of otolaryngologists.[5] Research has shown that soft-tissue surgery is considered less painful than any
skeletal surgery.[3] 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 surgeries
is low.[6]
[7]
[8]
[9]
[10] While reaching a similar conclusion, our study is the first to objectively examine
the quantity of opioid pain medication consumed between postoperative discharge and
office follow-up.
Methods
Patients undergoing partial, total, or complete thyroidectomy by four surgeons in
our teaching otolaryngology practice from August 2017 to December 2018 were considered
for our study. Appropriate Institutional Review Board approval was obtained (IRB#17–02–01).
Given the prospective and voluntary nature of our data collection, written informed
consent was obtained from each research subject. Exclusion criteria included chronic
neck pain, active opioid usage, age under 18, pregnancy, or incarceration.
The Centers for Disease Control (CDC) has provided a calculator to standardize the
morphine milligram equivalent (MME) across different varieties and strengths of pain
medication[11]
(
[Table 1]
). Utilizing MME allows for easier communication of pain data across different pain
medications. It is worth noting that 1 mg of oxycodone corresponds to 1.5 MME and
1 mg of hydrocodone corresponds to 1.0 MME.
Table 1
Centers for Disease Control (CDC) conversion chart for calculating morphine milligram
equivalents (MME)
|
Opioid (doses in mg/day, except where noted)
|
Conversion factor
|
|
Codeine
|
0.15
|
|
Fentanyl transdermal (in mcg/hr)
|
2.4
|
|
Hydrocodone
|
1
|
|
Hydromorphone
|
4
|
|
Methadone
|
|
|
1–20 mg/day
|
4
|
|
21–40 mg/day
|
8
|
|
41–60 mg/day
|
10
|
|
≥ 61–80 mg/day
|
12
|
|
Morphine
|
1
|
|
Oxycodone
|
1.5
|
|
Oxymorphone
|
3
|
The aim of the present study was to capture how many combination pills of 7.5 mg of
hydrocodone and 325 mg of acetaminophen patients used after hospital discharge for
up to 7 days. Prior to the study, our group's prescribing practices were based on
physician preference and prior experience. To satisfy the IRB mandate that study participation
would not limit access to pain medication postoperatively, we chose the upper range
of prescribing practices at 30 pills (225 MME).
It is our current practice to keep patients overnight after all thyroid surgeries.
On the day of discharge, consenting patients were enrolled in our study and given
a log sheet to keep track of the number of 7.5 mg hydrocodone 325 mg acetaminophen
combination pills they used per day at home. The log sheet included a copy of the
validated Wong-Baker faces pain rating scale to rate their average pain for each day
at home after discharge. Written permission was obtained from the Wong Baker Foundation
for usage of the scale in our study.[12]
Patients were instructed to bring their pill bottle to their first postoperative appointment,
which was at approximately one week postoperatively. At the follow-up appointment,
the log sheet was collected. The patient's remaining pills were counted in accordance
with the IRB approved protocol and any remaining pills were returned to the patient.
The in-office pill counts added a measure of objectivity to our study and eliminated
recall bias.
Patients were excluded if they failed to bring either the pill bottle or the log sheet
to the first follow-up appointment to maintain accuracy of the pill counts. A total
of 64/83 (77%) of the patients that originally consented to the study completed the
log sheet and brought their pill bottle to the first follow-up appointment as instructed.
At the conclusion of the study, data was analyzed retrospectively utilizing the patient's
medical record number from the log sheets to obtain relevant study information. Statistical
analysis was performed using IBM SPSS Statistics for Windows version 24 (IBM Corp,
Armonk, NY, USA) and included 2-tailed t-tests for comparison of continuous variables and linear regression analysis to evaluate
potential relationships amongst the number of tablets and average pain per day, length
of stay, age, gender, surgeon, hospital site, procedure, smoking status, number of
previous surgeries, number of allergies, number of medical comorbidities, weight,
and body mass index (BMI). Statistical significance threshold for 2-sided p-values was less than 0.01
Results
Sixty-four patients met the inclusion criteria, including returning to their first
postoperative appointment with their pill bottle and pain log sheet. The mean age
of the patients was 57.2 years, including 48 females (75%). No patient experienced
a postoperative complication that required return to the operating room. No patient
requested a refill of pain medication at the follow-up appointment.
Patients were prescribed a standard regimen of 30 combination pills of 7.5 mg of hydrocodone
and 325 mg of acetaminophen (225 MME). Twenty-five (39%) patients either did not fill
their prescription or used zero pills. There was no difference in pill consumption
between genders (p = 0.904), hospital at which the procedure took place (p = 0.550), nor smoking status (p = 0.506) (
[Table 2]
).
Table 2
Patient demographics that did not reach statistical significance
|
Number of patients
|
Mean pills per day
|
p-value
|
|
Gender
|
|
|
|
|
Male
|
16
|
0.7469
|
|
|
Female
|
48
|
0.7143
|
0.904
|
|
Hospital
|
|
|
|
|
A
|
35
|
0.7998
|
|
|
B
|
29
|
0.6650
|
0.550
|
|
Smoking status
|
|
|
|
|
Former
|
6
|
1.1548
|
|
|
Never
|
47
|
0.7096
|
|
|
Current
|
11
|
0.6364
|
0.506
|
|
Procedure
|
|
|
|
|
Hemithyroidectomy
|
28
|
0.7824
|
|
|
Total and complete
|
32; 4
|
0.7248
|
0.735
|
Pain per day did correlate strongly with pills consumed per day. Patients in more
pain subjectively consumed more pills objectively (p < 0.001) ([Fig. 1]). There was a statistically significant negative correlation between mean pills
per day and age, indicating that older patients tend to take fewer pills (r -0.404,
p = 0.001).
Fig. 1 Subjective pain scores correlated well with objective opioid pain medication consumption
There was no correlation with weight (p = 0.881), BMI (p = 0.521), length of hospital stay (p = 0.088), number of medication allergies (p = 0.839), number of prior surgeries (p = 0.848), number of home medications (0.278), nor number of medical comorbidities
(p = 0.340).
Discussion
At the beginning of our study, there was a paucity of evidence available to guide
prescribing patterns. The surgeons in our practice chose 7.5/325 mg hydrocodone/acetaminophen
pills over 5/325 mg hydrocodone/acetaminophen or oxycodone based on training and experience.
Our data supports the trend amongst recent publications indicating that pain is relatively
mild postoperatively after thyroid surgery for most patients. By utilizing pill counts,
we were able to objectively capture data on pill consumption for the first time in
the thyroid literature.
A common trend amongst published literature regarding the amount of opioid pain medication
prescribed postoperatively is a reduction in the amount of opioid medication prescribed
after analyzing patient consumption.[6]
[7]
[8]
[9]
[10]
[13]
[14] We, likewise, found this to be true for our practice.
Therapeutic use of opioids places the patient at increased risk for opioid abuse.[15] Overdose deaths involving prescription opioids were 5 times higher in 2017 than
in 1999. Opioids were involved in 47,600 overdose deaths in 2017 (67.8% of all drug
overdose deaths).[2]
Prescription opioids have been established as a gateway drug to heroin abuse. Moreover,
there has been a rise in fentanyl abuse, overdose, and death with prior prescription
opioid usage and heroin abuse as risk factors.[4]
[16] In 2015, a sharp increase in fentanyl drug confiscations and fentanyl-related overdose
fatalities lead the CDC and Drug Enforcement Administration (DEA) to issue a nationwide
health alert.[17]
[18]
Fortunately, there has been an increasing number of publications in recent years to
guide thyroid surgeon prescribing practices. In a 2017 article by Lou et al, the authors
surveyed 313 patients on opioid consumption after discharge from thyroid or parathyroid
surgery at the first postoperative visit. The average visit was 11 days postoperatively
and relied on accurate patient recall. In their study, the authors defined 1 MME as
equivalent to one tablet of hydrocodone/acetaminophen 5/325 mg. A total of 93% of
their patients had adequate pain control with 20 or fewer tablets. They recommended
discharge of patents with 20 tablets of hydrocodone/acetaminophen 5/325 mg. Prior
to the study, the authors averaged 30 tablets on discharge. In conventional MME, using
the CDC calculator the authors went from 150.0 to 100.0 MME.[6]
More recently, in 2018, a large cohort of 1,702 patients undergoing thyroid or parathyroid
surgery was examined by Shindo et al In their study, they examined the MME each patient
was discharged with and whether the patients called to request a refill for more opioid
pain medication or not. They found that patients who were prescribed 75.0 MME or less
did not call for a refill. An admitted limitation of the study by the authors was
that they did not capture consumption of opioids at home. Again, after examining their
prescribing practices, the authors decreased their average MME on discharge for parathyroidectomy
(176.20–80.08 MME), hemithyroidectomy (204.65–102.31 MME), and total thyroidectomy
(214.87–102.29). An important point highlighted in the article was the value of a
discussion in regards to postoperative pain expectations between physician and patient.
Counseling alone can lead to lower opioid use postoperatively.[7]
In another 2018 study by Long et al, the authors reported the average number of opioid
pills prescribed on discharge postoperatively to 237 thyroid and parathyroid surgery
patients was 43.1, with 84.4% receiving oxycodone/acetaminophen (323 MME). The authors
also acknowledged that a limitation of their study was no data was captured after
hospital discharge and that after the study they have reduced their prescribing quantities.[8]
Another recent study published in 2018 by Tharakan et al showed that more than 80%
of 209 patients undergoing total thyroidectomy, hemi thyroidectomy, and parathyroidectomy
were able to have adequate pain control with 10 or fewer opioid pills. They conducted
phone surveys and a variety of pain medications were prescribed on discharge. The
majority of patients received 20 to 30 oxycodone 5-mg pills (150–225 MME). They found
that older age was associated with lower pill consumption, and Charleston comorbidity
index greater than 5 was associated with increased pill consumption. Again, telephone
surveys were used, which introduces recall bias.[9]
Perhaps, the most promising paper published in the last 2 years is by Militsakh et
al in 2018, which showed the safety and effectiveness of multimodality anesthesia
(MMA) for patients undergoing thyroid and parathyroid surgery. In their series of
528 patients spanning 3 calendar years, only 3 out of the 162 patients (1.9%) enrolled
in the MMA treatment pathway in 2017 required an opioid prescription on discharge.
Briefly, patients received a combination of acetaminophen, ibuprofen, and gabapentin
by mouth preoperatively. Postoperatively, patients were instructed to alternate acetaminophen
and ibuprofen on a scheduled basis every 6 hours for the first 48 hours postoperatively.
Only one hematoma was reported in the study cohort, and it was a patient involved
in a motor vehicle accident as an unrestrained passenger. There were no reports of
renal injury requiring unplanned hospital readmission.[10]
Our study was designed to objectively capture the amount of opioid pain medication
consumed by patients at home after hospital discharge to determine an appropriate
level of MME for discharge.
Limitations of our study include a possible Hawthorne effect, single practice study,
lack of standardized anesthesia regimen, and exclusion of patients with an active
opioid prescription. Although the anesthesia before, during, and immediately after
the procedures was not standardized, it can be assumed that clinical standards of
anesthesia were appropriately met. Furthermore, there was no difference in pain levels
or pill consumption between the hospital cohorts. Long et al did note an increased
level of pain and MME requirement for patients with an active opioid prescription
while in the hospital.[8] An area of future research would be to determine if this patient population requires
more opioids. According to their published article, a cohort of such patients is being
examined by Shindo et al currently.[7]
With increasingly restrictive laws requiring paper-only written prescriptions, surgeons
must be cognizant of providing patients with enough pain medication to treat postoperative
pain appropriately and maintain patient satisfaction, particularly patients that may
live a great distance from the hospital or in another state.
Future areas of research would include but are not limited to continued postoperative
pain research in other common head and neck procedures, a double-blinded study to
investigate if one opioid is more effect than another or versus nonopioid medication
and the effects of multimodality anesthesia (MMA) on patients' opioids needs after
discharge. Militsakh et al have provided strong evidence that opioid prescriptions
may be avoidable with MMA. Their work also demonstrates safety of incorporating nonsteroidal
antiinflammatory drugs (NSAIDs) into MMA before and after surgery without an increased
bleeding risk.[10]
Conclusion
The present study objectively demonstrates that 85% of patients consumed fewer than
75.0 MME after thyroid surgery using in-office pill counts. Recent MMA research appears
promising to dramatically reduce or even eliminate the need for opioid prescriptions
upon postoperative discharge.
