Comparison of Opioid Utilization Patterns after Major Head and Neck Procedures between Hong Kong and the United States

Ryan Li, Myriam Loyo Li, Enrique Leon, Cherrie W.K. Ng, Maisie Shindo, Katie Manzione, Peter Andersen, Daniel Clayburgh, Mark Wax, Jason Y.K. Chan

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Importance: The current opioid abuse epidemic in the United States requires evaluation of prescribing practices within all medical specialties. This examination includes a review of postoperative pain management for patients undergoing major head and neck procedures. Objective: To report differences in postoperative pain regimens between an international and domestic head and neck surgical program. Design, Setting, and Participants: Pain management patterns after head and neck surgery in the programs at Chinese University of Hong Kong (CUHK) and Oregon Health and Science University (OHSU) were compared with a focus on opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen or paracetamol, and anxiolytics. Cases from July 1, 2013, through August 31, 2017, were reviewed. Standing medication orders the day before surgery (PRE1), postoperative day 6 (POD6), and postoperative day 14 (POD14) were compared between institutions. Exposures: Head and neck surgery. Results: A total of 253 cases from CUHK and 567 cases from OHSU were analyzed (mean [SD] age, 59.4 [14.3] and 60.1 [16.4] years, respectively). Patients from OHSU had a significantly higher frequency of opioid orders on PRE1 (15.3% vs 1.6%; odds ratio [OR], 11.3; 95% CI, 4.09-31.10), POD6 (86.8% vs 0.4%; OR, 1653.12; 95% CI, 228.51-11959.01), and POD14 (71.4% vs 0.8%; OR, 313.75; 95% CI, 77.12-1276.52). There were no significant differences in acetaminophen or paracetamol, NSAID, or anxiolytic orders between institutions. Institution was the most significant indicator for the presence of opioid orders on POD6 (OR, 4271.10; 95% CI, 380.04-47 999.70) and POD14 (OR, 330.35; 95% CI, 79.67-1369.82). In addition to treating institution, multivariate analysis showed that PRE1 opioid orders indicated a significant increase in likelihood of opioid orders on POD6 (OR, 4.77; 95% CI, 1.23-18.57) but not POD14. POD6 anxiolytic orders remained a significant indicator of opioid orders for POD6 (95% CI, 1.49-113.10) and POD14 (95% CI, 1.17-5.03), respectively. Conclusions and Relevance: A significantly lower frequency of postoperative opioid orders was observed from CUHK compared with OHSU across similar major head and neck procedures. This contrast encourages a careful 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 use, and (4) alternatives to opioid pain regimens. A thoughtful shift in postoperative pain protocols that deemphasizes opioid use may be an opportunity to counter the epidemic of opioid abuse in the United States.

Original languageEnglish (US)
Pages (from-to)E1-E6
JournalJAMA Otolaryngology - Head and Neck Surgery
DOIs
StateAccepted/In press - Jan 1 2018

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Hong Kong
Opioid Analgesics
Neck
Head
Odds Ratio
Acetaminophen
Anti-Anxiety Agents
Postoperative Pain
Health
Pain Management
Anti-Inflammatory Agents
Pain
Ambulatory Surgical Procedures
Pharmaceutical Preparations
Industry
Multivariate Analysis
Economics
Medicine

ASJC Scopus subject areas

  • Surgery
  • Otorhinolaryngology

Cite this

Comparison of Opioid Utilization Patterns after Major Head and Neck Procedures between Hong Kong and the United States. / Li, Ryan; Loyo Li, Myriam; Leon, Enrique; Ng, Cherrie W.K.; Shindo, Maisie; Manzione, Katie; Andersen, Peter; Clayburgh, Daniel; Wax, Mark; Chan, Jason Y.K.

In: JAMA Otolaryngology - Head and Neck Surgery, 01.01.2018, p. E1-E6.

Research output: Contribution to journalArticle

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abstract = "Importance: The current opioid abuse epidemic in the United States requires evaluation of prescribing practices within all medical specialties. This examination includes a review of postoperative pain management for patients undergoing major head and neck procedures. Objective: To report differences in postoperative pain regimens between an international and domestic head and neck surgical program. Design, Setting, and Participants: Pain management patterns after head and neck surgery in the programs at Chinese University of Hong Kong (CUHK) and Oregon Health and Science University (OHSU) were compared with a focus on opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen or paracetamol, and anxiolytics. Cases from July 1, 2013, through August 31, 2017, were reviewed. Standing medication orders the day before surgery (PRE1), postoperative day 6 (POD6), and postoperative day 14 (POD14) were compared between institutions. Exposures: Head and neck surgery. Results: A total of 253 cases from CUHK and 567 cases from OHSU were analyzed (mean [SD] age, 59.4 [14.3] and 60.1 [16.4] years, respectively). Patients from OHSU had a significantly higher frequency of opioid orders on PRE1 (15.3{\%} vs 1.6{\%}; odds ratio [OR], 11.3; 95{\%} CI, 4.09-31.10), POD6 (86.8{\%} vs 0.4{\%}; OR, 1653.12; 95{\%} CI, 228.51-11959.01), and POD14 (71.4{\%} vs 0.8{\%}; OR, 313.75; 95{\%} CI, 77.12-1276.52). There were no significant differences in acetaminophen or paracetamol, NSAID, or anxiolytic orders between institutions. Institution was the most significant indicator for the presence of opioid orders on POD6 (OR, 4271.10; 95{\%} CI, 380.04-47 999.70) and POD14 (OR, 330.35; 95{\%} CI, 79.67-1369.82). In addition to treating institution, multivariate analysis showed that PRE1 opioid orders indicated a significant increase in likelihood of opioid orders on POD6 (OR, 4.77; 95{\%} CI, 1.23-18.57) but not POD14. POD6 anxiolytic orders remained a significant indicator of opioid orders for POD6 (95{\%} CI, 1.49-113.10) and POD14 (95{\%} CI, 1.17-5.03), respectively. Conclusions and Relevance: A significantly lower frequency of postoperative opioid orders was observed from CUHK compared with OHSU across similar major head and neck procedures. This contrast encourages a careful 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 use, and (4) alternatives to opioid pain regimens. A thoughtful shift in postoperative pain protocols that deemphasizes opioid use may be an opportunity to counter the epidemic of opioid abuse in the United States.",
author = "Ryan Li and {Loyo Li}, Myriam and Enrique Leon and Ng, {Cherrie W.K.} and Maisie Shindo and Katie Manzione and Peter Andersen and Daniel Clayburgh and Mark Wax and Chan, {Jason Y.K.}",
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AU - Leon, Enrique

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AU - Shindo, Maisie

AU - Manzione, Katie

AU - Andersen, Peter

AU - Clayburgh, Daniel

AU - Wax, Mark

AU - Chan, Jason Y.K.

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AB - Importance: The current opioid abuse epidemic in the United States requires evaluation of prescribing practices within all medical specialties. This examination includes a review of postoperative pain management for patients undergoing major head and neck procedures. Objective: To report differences in postoperative pain regimens between an international and domestic head and neck surgical program. Design, Setting, and Participants: Pain management patterns after head and neck surgery in the programs at Chinese University of Hong Kong (CUHK) and Oregon Health and Science University (OHSU) were compared with a focus on opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen or paracetamol, and anxiolytics. Cases from July 1, 2013, through August 31, 2017, were reviewed. Standing medication orders the day before surgery (PRE1), postoperative day 6 (POD6), and postoperative day 14 (POD14) were compared between institutions. Exposures: Head and neck surgery. Results: A total of 253 cases from CUHK and 567 cases from OHSU were analyzed (mean [SD] age, 59.4 [14.3] and 60.1 [16.4] years, respectively). Patients from OHSU had a significantly higher frequency of opioid orders on PRE1 (15.3% vs 1.6%; odds ratio [OR], 11.3; 95% CI, 4.09-31.10), POD6 (86.8% vs 0.4%; OR, 1653.12; 95% CI, 228.51-11959.01), and POD14 (71.4% vs 0.8%; OR, 313.75; 95% CI, 77.12-1276.52). There were no significant differences in acetaminophen or paracetamol, NSAID, or anxiolytic orders between institutions. Institution was the most significant indicator for the presence of opioid orders on POD6 (OR, 4271.10; 95% CI, 380.04-47 999.70) and POD14 (OR, 330.35; 95% CI, 79.67-1369.82). In addition to treating institution, multivariate analysis showed that PRE1 opioid orders indicated a significant increase in likelihood of opioid orders on POD6 (OR, 4.77; 95% CI, 1.23-18.57) but not POD14. POD6 anxiolytic orders remained a significant indicator of opioid orders for POD6 (95% CI, 1.49-113.10) and POD14 (95% CI, 1.17-5.03), respectively. Conclusions and Relevance: A significantly lower frequency of postoperative opioid orders was observed from CUHK compared with OHSU across similar major head and neck procedures. This contrast encourages a careful 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 use, and (4) alternatives to opioid pain regimens. A thoughtful shift in postoperative pain protocols that deemphasizes opioid use may be an opportunity to counter the epidemic of opioid abuse in the United States.

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