Differences in opioid utilization after major head and neck procedures: a comparison of institutions in Hong Kong and the United States.

Presentation: AHNS048
Topic: Quality of Care and Clinical Pathways
Type: Oral
Date: Thursday, April 19, 2018
Session: 1:00 PM - 1:50 PM Best Papers of AHNS 2018
Authors: Ryan J Li, MD1, Jason YK Chan, MD2
Institution(s): 1Oregon Health and Science University, 2Chinese University of Hong Kong

Importance: The current opioid abuse epidemic in the United States warrants evaluation of prescribing practices within all medical specialties. This includes a review of postoperative pain management for patients undergoing major head and neck procedures.  Comparison with international pain management practices can illuminate opportunities for more judicious utilization of opioid and non-opioid pain medications.

Objective: To report differences in postoperative pain regimens between an international and domestic surgical program, for patients undergoing major head and neck surgical procedures.

Design, Setting, and Participants: The head and neck surgery programs at the Chinese University of Hong Kong (CUHK) and Oregon Health and Science University (OHSU) retrospectively reviewed pain management patterns after major head and neck surgical procedures, focusing on opioids, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and select anxiolytics. Gabapentinoids were not utilized at CUHK and therefore were not included in our analysis. Cases from November, 2014 through August, 2017 were reviewed. Standing medication orders on postoperative day one (POD1), six (POD6), and fourteen (POD14) were compared between institutions. Student’s t-test was used to compare continuous variables, Chi-square for categorical variables, and multivariate regression for factors associated with opioid ordering.

Exposures: Major head and neck surgery.

Results: A total of 250 patient cases from CUHK, and 386 patients from OHSU were analyzed (mean [SD] age, 59.9 [1.68] and 62.5 [0.76] years, respectively). There was no difference in gender distribution, or the distribution of major head and neck procedures (including glossectomy, pharyngectomy, laryngectomy, mandibulectomy, neck dissection, and free tissue transfer) between institutions.  CUHK patients had a markedly lower frequency of opioid orders on POD1 (4% vs. 86%, P<0.001), POD6 (13% vs. 84%, P<0.001), and POD14 (5% vs. 69%, P=0.004). There was no difference in acetaminophen orders between institutions (CUHK vs. OHSU) at POD1 (76% vs. 80%, P=0.867), POD6 (74% vs. 79%, P=0.810), and POD14 (73% vs. 69%, P=0.793). CUHK patients had a higher frequency of NSAID orders on POD1 (12% vs. 2%, P<0.001), POD6 (17% vs. 3%, P<0.001), and POD14 (17% vs. 9%, P=0.003). CUHK patients had a lower frequency of anxiolytic orders on POD1 (12% vs. 26%, P< 0.001), POD6 (15% vs. 27%, P<0.001), and POD14 (12% vs. 20%, P=0.004). On multivariate analysis, surgery at CUHK was associated with a 6-fold decreased likelihood of opioid orders on POD1 (P<0.001), 3-fold decrease on POD6 (P<0.001), and 5-fold decrease on POD14 (P<0.001). Conversely, age, gender, types of procedure, acetaminophen, NSAID, and anxiolytic orders were not significantly associated with opioid orders.

Conclusions and Relevance: A markedly lower frequency of postoperative opioid orders was observed from CUHK (Hong Kong) compared to OHSU (Oregon, USA), across similar major head and neck procedures. This stark contrast encourages a critical examination of 1] cultural and patient expectations of pain control; 2] the metrics by which control is assessed; 3] industry and economic drivers of opioid usage; and 4] strategies to reduce opioid orders. A thoughtful shift in postoperative pain protocols that deemphasizes opioid usage may be an opportunity to counter the epidemic of opioid abuse in the United States.