Opioid Prescribing in Patients Undergoing Neck Dissection for Thyroid Malignancy

Presentation: AHNS30
Topic: Endocrine Surgery
Type: Oral
Date: Thursday, April 28, 2022
Session: 9:00 AM – 9:45 AM Endocrine
Authors: Jennifer March; James Lim; Maisie Shindo
Institution(s): Oregon Health and Science University


Background:

Opioid prescribing practices for endocrine surgery have been reported in several studies.  Data is lacking on opioid needs when lateral neck dissection is performed in this patient population. Our group recently described an opioid reduction initiative for routine thyroidectomy and parathyroidectomy which included preoperative counseling, multimodality non-opioid pain management, and joint efforts between RNs and MDs in assessing and treating the pain in the acute postoperative period, and demonstrated significant a reduction in quantity of postoperative opioids prescribed. We expanded the application of these interventions to patients undergoing lateral neck dissection for thyroid malignancy to determine if opioid prescribing can be reduced for such procedures.

Methods: We performed a retrospective cohort study of 397 patients who underwent lateral neck dissection for management of thyroid malignancy at Oregon Health and Science University, with or without central compartment surgery, between 6/2011 and 4/2021.  Group 1 contained 165 patients treated prior to implementation of our multimodal pain control initiative.  Group 2 contained 232 patients treated after implementation of decreased opioid prescribing practices.  We evaluated the quantity of opioids prescribed at discharge and refills requested.  Since these procedures are performed by endocrine surgery, head and neck surgery and surgical oncology services at our institution, we performed a subgroup analysis to determine if opioid prescribing differed between the groups.

Results: Cohort characteristics were compared between the patients included in Group 1 and Group 2.  There was no statistically significant difference in the distribution of patients based on gender, race, length of hospital stay, subtype of thyroid malignancy, and procedures performed.  The median morphine milliequivalents (MME) prescribed at discharge in Group 1 was 225, compared to 0 for the patients in Group 2 after implementation of our initiative (p<0.0001).  There was no statistically significant difference in the number of patients who requested opioid refills between the groups.  All treating services had a statistically significant decrease in opioids prescribed at discharge after implementation of the protocol: median 225 MME in endocrine group 1 compared to 0 MME in endocrine group 2 (p<0.01), median 200 MME in H&N group 1 compared to 75 MME in H&N group 2 (p<0.01), and median 225 MME in surgical oncology group 1 compared to 67.5 MME in group 2 (p<0.01).  After implementation of the protocol, 57% of patients were discharged without a prescription for opioids, compared to only 7% before we changed our practice (p=<0.00001).  The pattern of decreased MME required for pain control was maintained regardless of the extent of surgery performed with unilateral neck dissection, unilateral neck dissection with central compartment surgery, bilateral neck dissection, and bilateral neck dissection with central compartment surgery all demonstrating a statistically significant decrease (p<0.05 for all).

Conclusions: There was a statistically significant decrease in opioid prescriptions at discharge after implementation of preoperative counseling and perioperative pain management strategies for patients undergoing lateral neck dissection for management of thyroid malignancy.  Based on these results, the median need for these procedures is between 0-75 MME (10 tablets of 5mg oxycodone) for opioid naïve patients.