Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland.
Department of Otorhinolaryngology-Head and Neck Surgery, Chinese University of Hong Kong, Kowloon, Hong Kong.
JAMA Otolaryngol Head Neck Surg. 2018 Nov 1;144(11):1060-1065. doi: 10.1001/jamaoto.2018.1787.
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.
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.
Head and neck surgery.
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, 228.51-11 959.01), 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.
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.
重要性：当前美国阿片类药物滥用的流行情况需要对所有医学专业的处方实践进行评估。这包括对接受重大头颈部手术的患者的术后疼痛管理进行审查。
目的：报告中美大学（香港中文大学）和俄勒冈健康与科学大学（OHSU）头颈部外科项目之间术后疼痛方案的差异。
设计、地点和参与者：比较了 2013 年 7 月 1 日至 2017 年 8 月 31 日期间香港中文大学和俄勒冈健康与科学大学的头颈部手术后的疼痛管理模式，重点是阿片类药物、非甾体抗炎药（NSAIDs）、对乙酰氨基酚或扑热息痛和镇静剂。比较了术前一天（PRE1）、术后第 6 天（POD6）和术后第 14 天（POD14）的机构间常规药物医嘱。
暴露：头颈部手术。
结果：分析了来自香港中文大学的 253 例病例和来自 OHSU 的 567 例病例（平均[SD]年龄，59.4[14.3]和 60.1[16.4]岁）。OHSU 的患者在 PRE1（15.3%比 1.6%；比值比[OR]，11.3；95%CI，4.09-31.10）、POD6（86.8%比 0.4%；OR，1653.12；95%CI，228.51-11959.01）和 POD14（71.4%比 0.8%；OR，313.75；95%CI，77.12-1276.52）时开具阿片类药物处方的频率明显更高。机构间没有在对乙酰氨基酚或扑热息痛、非甾体抗炎药或镇静剂的处方方面存在显著差异。机构是 POD6（OR，4271.10；95%CI，380.04-47999.70）和 POD14（OR，330.35；95%CI，79.67-1369.82）存在阿片类药物处方的最重要指标。除了治疗机构外，多变量分析显示 PRE1 阿片类药物处方表明 POD6 阿片类药物处方的可能性显著增加（OR，4.77；95%CI，1.23-18.57），但对 POD14 没有影响。POD6 镇静剂处方仍然是 POD6（95%CI，1.49-113.10）和 POD14（95%CI，1.17-5.03）阿片类药物处方的显著指标。
结论和相关性：与 OHSU 相比，香港中文大学在接受类似的主要头颈部手术的患者中，术后阿片类药物处方的频率明显较低。这种对比促使人们仔细研究（1）对疼痛控制的文化和患者期望，（2）控制的评估指标，（3）阿片类药物使用的行业和经济驱动因素，以及（4）阿片类药物疼痛方案的替代方案。强调减少阿片类药物使用的术后疼痛方案的深思熟虑的转变可能是对抗美国阿片类药物滥用流行的机会。
