Introduction: The overprescription of opioids following surgery is one of the drivers of the opioid epidemic in the United States, highlighting the need to reform prescribing practices. However, there is limited data regarding patient-reported pain outcomes after surgery, leaving surgeons without practical guidelines for postoperative pain management.
Objective: The purpose of this study was to evaluate patient-reported pain and opioid use after two common outpatient head and neck surgeries – hemithyroidectomy and cervical lymph node biopsy – and potentially identify factors associated with increased pain and opioid use.
Methods: Patients undergoing hemithyroidectomy and cervical lymph node biopsy (CLNB) were prospectively enrolled from June 2017 to September 2018. Of the 24 total patients, 10 underwent CLNB and 14 underwent hemithyroidectomy. Preoperative surveys were used to collect baseline demographic information, history of chronic pain and analgesic use, and scores from two psychosocial instruments to assess patient attitudes about pain and clinically relevant mood disturbance – the Pain Catastrophizing Scale (PCS) and the Hospital Anxiety and Depression Scale (HADS). Following surgery, patients recorded daily peak pain levels on a 10 cm visual analog scale (VAS) along with daily opioid and non-opioid analgesic use. The latter was converted into morphine milligram equivalents (MME) to allow comparison among various analgesic formulations, while pain levels were measured in millimeters to generate a score between 0 and 100.
Results: Average pain levels were 32, 12, and 2 on postoperative days 1, 3, and 7, respectively. Average opioid use was 6.69, 1.25, and 0.31 mg (MME) over the same study days. Patients reported an average cumulative opioid requirement of 17.72 mg, with a median 18 pills leftover at the end of the study period. Cumulative pain ratings were correlated positively with cumulative opioid use (R2=0.95). The majority of patients transitioned off of opioid analgesics early, with only a few patients requiring opioids beyond postoperative day 2. Univariate analysis revealed that patients who underwent CLNB had increased opioid requirements compared to those who underwent hemithyroidectomy (28.88 vs 9.75 mg, p=0.04), but did not report a significant increase in postoperative pain (117 vs 120, p=0.93). Age, gender, marital status, and education level were not associated with statistically significant differences in postoperative pain or opioid use. Stratification of patients based on preoperative psychometric instrument scores similarly did not correlate with differences in the two outcome measures.
Conclusion: Patients undergoing hemithyroidectomy and cervical lymph node biopsy, in general, have low subjective daily pain and opioid requirements after surgery. There was a statistically significant difference in opioid use between patients undergoing lymph node biopsy versus hemithyroidectomy, which was not associated with increased subjective pain scores. Overall, there was a strong correlation between patient-reported pain and opioid use. Our results suggest that the majority of patients undergoing ambulatory head and neck surgery require 10 or fewer doses of prescription opioid pain medications for postoperative pain management.