1
|
Elliott ZT, Mann DS, Fiorella M, Christopher V, Givens A, Martin AM, Zhan T, Curry J. Predictors of opioid requirement among patients receiving free flap reconstruction to the head and neck. Am J Otolaryngol 2023; 44:104000. [PMID: 37499343 DOI: 10.1016/j.amjoto.2023.104000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Opioids are a part of standard of care treatment of acute, severe postoperative pain. However, increased opioid requirements have been shown to be associated with increased postoperative complications, morbidity, and mortality. The aim of this study was to identify potential predictive factors associated with increased or decreased opioid requirements after free tissue transfer (FTT) to the head and neck. MATERIALS/METHODS A retrospective review was conducted on subjects who underwent head and neck reconstruction (HNR) from 2015 to 2021 at a single tertiary care center. Patients with inpatient stay over 10 days and those receiving fentanyl for sedation purposes were excluded due to EMR limitations and confounding, respectively. The total dose of opioid medication each patient received was calculated and summed using morphine milligram equivalents (MME). Statistical analysis was conducted using poisson regression and multivariable regression models. RESULTS Two hundred and ninety-one patients were included. The mean opioid requirement for all subjects was 228.6 (SD 250.0) MMEs during their entire postoperative stay and the mean length of stay was 6.0 (SD 1.7) days. An established opioid prescription prior to surgical resection was the greatest predictor of increased risk for opioid requirement according univariate and multivariate analysis 2.356 (2.321-2.392), p ≤ 0.0001 and 1.833 (1.802-1.863), p ≤ 0.0001, respectively. Fibula transfers were associated with higher opioid requirements while scapula transfers were associated with decreased opioid requirements compared to other free tissue transfer types. CONCLUSION Preoperative opioid use was associated with higher postoperative opioid requirements. Multimodal pain management (MMPM) was not associated with a decreased opioid requirement; however, further studies are needed to investigate the hierarchy, dosing, and timing of MMPM in relation to opioid requirements and pain control.
Collapse
Affiliation(s)
- Zachary T Elliott
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA.
| | - Derek S Mann
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Michele Fiorella
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Vanessa Christopher
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Alyssa Givens
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Ann Marie Martin
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA 191071, USA
| | - Joseph Curry
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| |
Collapse
|
2
|
Trakimas DR, Colloca L, Fakhry C, Tan M, Khan Z, Vosler PS. Study protocol: randomised controlled trial of conditioned open-label placebo (COLP) for perioperative pain management in patients with head and neck cancer. BMJ Open 2023; 13:e069785. [PMID: 37419646 PMCID: PMC10335570 DOI: 10.1136/bmjopen-2022-069785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 06/11/2023] [Indexed: 07/09/2023] Open
Abstract
INTRODUCTION Patients with head and neck cancer have a substantial risk of chronic opioid dependence following surgery due to pain and psychosocial consequences from both the disease process and its treatments. Conditioned open-label placebos (COLPs) have been effective for reducing the dose of active medication required for a clinical response across a wide range of medical conditions. We hypothesise that the addition of COLPs to standard multimodal analgesia will be associated with reduced baseline opioid consumption by 5 days after surgery in comparison to standard multimodal analgesia alone in patients with head and neck cancer. METHODS AND ANALYSIS This randomised controlled trial will evaluate the use of COLP for adjunctive pain management in patients with head and neck cancer. Participants will be randomised with 1:1 allocation to either the treatment as usual or COLP group. All participants will receive standard multimodal analgesia, including opioids. The COLP group will additionally receive conditioning (ie, exposure to a clove oil scent) paired with active and placebo opioids for 5 days. Participants will complete surveys on pain, opioid consumption and depression symptoms through 6 months after surgery. Average change in baseline opioid consumption by postoperative day 5 and average pain levels and opioid consumption through 6 months will be compared between groups. ETHICS AND DISSEMINATION There remains a demand for more effective and safer strategies for postoperative pain management in patients with head and neck cancer as chronic opioid dependence has been associated with decreased survival in this patient population. Results from this study may lay the groundwork for further investigation of COLPs as a strategy for adjunctive pain management in patients with head and neck cancer. This clinical trial has been approved by the Johns Hopkins University Institutional Review Board (IRB00276225) and is registered on the National Institutes of Health Clinical Trials Database. TRIAL REGISTRATION NUMBER NCT04973748.
Collapse
Affiliation(s)
- Danielle R Trakimas
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science | Placebo Beyond Opinion Center, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Carole Fakhry
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Marietta Tan
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Zubair Khan
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Peter S Vosler
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| |
Collapse
|
3
|
Nugent SM, Slatore CG, Winchell K, Handley R, Clayburgh D, Chandra R, Hooker ER, Knight SJ, Morasco BJ. Prevalence and correlates of high-dose opioid use among survivors of head and neck cancer. Head Neck 2023. [PMID: 37366072 DOI: 10.1002/hed.27432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/14/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND We characterized prescription opioid medication use up to 2 years following the head and neck cancer (HNC) diagnosis and examined associations with moderate or high daily opioid prescription dose. METHODS Using administrative data from Veterans Health Administration, we conducted a retrospective cohort analysis of 5522 Veterans treated for cancers of the upper aerodigestive tract between 2012 and 2019. Data included cancer diagnosis and treatments, pain severity, prescription opioid characteristics, demographics, and other clinical factors. RESULTS Two years post-HNC, 7.8% (n = 428) were receiving moderate or high-dose opioid therapy. Patients with at least moderate pain (18%, n = 996) had 2.48 times higher odds (95% CI = 1.94-3.09, p < 0.001) to be prescribed a moderate opioid dose or higher at 2 years post diagnosis. CONCLUSIONS Survivors of HNC with at least moderate pain were at elevated risk of continued use of moderate and high dose opioids.
Collapse
Affiliation(s)
- Shannon M Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Department of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA
| | - Kara Winchell
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Robert Handley
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Daniel Clayburgh
- VA Portland Health Care Center, Head and Neck Surgery, Portland, Oregon, USA
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, USA
| | - Ravi Chandra
- Department of Radiology, Oregon Health & Science Center, Portland, Oregon, USA
- Department of Radiation Oncology, Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Sara J Knight
- Informatics, Decisions-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Medicine, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
4
|
Trakimas DR, Perez-Heydrich C, Mandal R, Tan M, Gourin CG, Fakhry C, Koch WM, Russell JO, Tufano RP, Eisele DW, Vosler PS. Peri-Operative Pain and Opioid Use in Opioid-Naïve Patients Following Inpatient Head and Neck Surgery. Front Psychiatry 2022; 13:857083. [PMID: 35873237 PMCID: PMC9305070 DOI: 10.3389/fpsyt.2022.857083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Pain management is an important consideration for Head and Neck Cancer (HNC) patients as they are at an increased risk of developing chronic opioid use, which can negatively impact both quality of life and survival outcomes. This retrospective cohort study aimed to evaluate pain, opioid use and opioid prescriptions following HNC surgery. Participants included patients undergoing resection of a head and neck tumor from 2019-2020 at a single academic center with a length of admission (LOA) of at least 24 h. Exclusion criteria were a history of chronic pain, substance-use disorder, inability to tolerate multimodal analgesia or a significant post-operative complication. Subjects were compared by primary surgical site: Neck (neck dissection, thyroidectomy or parotidectomy), Mucosal (resection of tumor of upper aerodigestive tract, excluding oropharynx), Oropharyngeal (OP) and Free flap (FF). Average daily pain and total daily opioid consumption (as morphine milligram equivalents, MME) and quantity of opioids prescribed at discharge were compared. A total of 216 patients met criteria. Pain severity and daily opioid consumption were comparable across groups on post-operative day 1, but both metrics were significantly greater in the OP group on the day prior to discharge (DpDC) (5.6 (1.9-8.6), p < 0.05; 49 ± 44 MME/day, p < 0.01). The quantity of opioids prescribed at discharge was associated with opioid consumption on the DpDC only in the Mucosal and FF groups, which had longer LOA (6-7 days) than the Neck and OP groups (1 day, p < 0.001). Overall, 65% of patients required at least one dose of an opioid on the DpDC, yet 76% of patients received a prescription for an opioid medication at discharge. A longer LOA (aOR = 0.82, 95% CI: 0.63-0.98) and higher Charlson Comorbidity Index (aOR = 0.08, 95% CI: 0.01-0.48) were negatively associated with receiving an opioid prescription at the time of discharge despite no opioid use on the DpDC, respectively. HNC patients, particularly those with shorter LOA, may be prescribed opioids in excess of their post-operative needs, highlighting the need the for improved pain management algorithms in this patient population. Future work aims to use prospective surveys to better define post-operative and outpatient pain and opioid requirements following HNC surgery.
Collapse
Affiliation(s)
- Danielle R Trakimas
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Carlos Perez-Heydrich
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Rajarsi Mandal
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Marietta Tan
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Christine G Gourin
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Carole Fakhry
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Wayne M Koch
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Jonathon O Russell
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Ralph P Tufano
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - David W Eisele
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Peter S Vosler
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| |
Collapse
|