Objectives: The current opioid crisis has highlighted concerns raised in chronic pain management. Pain related to head and neck cancer, and the sequela of undergoing major surgery followed by adjuvant treatment, poses a significant treatment challenge to providers. This study assessed the characteristics of opioid use in patients undergoing free flap surgery for previously untreated head and neck cancer, and analyzed risk factors for chronic opioid use.
Methods: A retrospective cohort study was conducted for 117 eligible patients who underwent primary resection with microvascular free flap reconstruction for squamous cell carcinoma of the head and neck, at a single institution from 2012-2017. Patients previously treated for head and neck cancer, follow-up less than 6 months, or distant metastasis at presentation were excluded. Opioid use was recorded at 3, 6 and 12 months post-operatively. Chronic opioid use was defined as the use of narcotics 3 months (or more) post-operatively. Statistical analysis was performed to assess risk factors for chronic opioid use.
Results: The average age was 63 years and mean follow-up was 22 months. All patients underwent free flap surgery for previously untreated head and neck squamous cell carcinoma of the oral cavity (68%), larynx (20%) or skin (11%). The majority of patients underwent reconstruction with radial forearm flaps (61%), followed by fibula flaps (33%) and anterolateral thigh flaps (12%). 87% of patients had stage III/IV disease, 82% received adjuvant radiotherapy (RT) or chemoradiotherapy (CRT) and there were 32 recurrences. 24 (21%) patients had pre-existing chronic pain conditions. Chronic opioid use at 3 months and 6 months post-operatively was 85% and 75% respectively. History of depression (p=0.0293), smoking (0.0033), oral cavity sub site (p=0.0276), and presence of a pre-existing chronic pain condition (p=0.0028) were associated with chronic opioid use. Advanced T stage, N positive disease, recurrence, adjuvant treatment modality (RT versus CRT), and free flap type were not significantly associated with chronic opioid use.
Conclusion: Chronic opioid use in head and neck cancer patients undergoing free flap surgery is highly prevalent. Given the intense treatment needed for this disease, and consequent debilitating side effects, identifying patients at greatest risk for chronic opioid use prior to treatment may help with long-term pain management in this patient population.