Non-Narcotic Multimodal Analgesia in Head and Neck Surgery:

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1 Non-Narcotic Multimodal Analgesia in Head and Neck Surgery: Feasibility, Safety and Impact on Physician Prescribing Practices Aru Panwar, MD FACS Methodist Estabrook Cancer Center, Omaha, Nebraska 2018 NANA Fall Convention, Lincoln, Nebraska October 14, 2018

2 Disclosures No relevant financial disclosures

3 An Epidemic of Drug Overdose Deaths in the United States

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9 The Problem Head and Neck surgical procedures rely heavily on opioidbased analgesia Numerous negative consequences of opioid analgesia 1 Addiction Potential Opiate related adverse events Societal costs Controlled substance regulation Multimodal analgesia techniques incorporate non-narcotic agents 2 1 Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA Mar 21;317(11): Dort JC, Farwell DG, Findlay M, Huber GF, Kerr P, Shea-Budgell MA, Simon C, Uppington J, Zygun D, Ljungqvist O, Harris J. Optimal Perioperative Care in Major Head and Neck Cancer Surgery with Free Flap Reconstruction: A Consensus Review and Recommendations from the Enhanced Recovery After Surgery Society. JAMA Otolaryngol Head Neck Surg Mar 1;143(3):

10 Multimodal analgesia

11 Study 1: Feasibility and Safety of Multimodal Analgesia Key question: Can multimodal analgesia techniques be safely applied in patients undergoing outpatient head and neck surgery? Thyroidectomy Parathyroidectomy Parotidectomy 64 adult patients Retrospective review of prospectively collected data (July 2016 to February 2017)

12 Multimodal analgesia Non-narcotic post-operative analgesia Ibuprofen 600 mg po q6h Acetaminophen 500 mg po q6h Escalation to narcotics permitted, as indicated CLINIC Patient counseling INTRA-OP Pre-incision local anesthetic injection Prudent use of inhalational/ IV agents Routine surgical technique DAY OF SURGERY PRE-OP Counseling PRE-OP Single oral dose: Gabapentin mg APAP 1000 mg Meloxicam 7.5mg Use of post-operative discharge narcotics identified (failure of strategy) Poor analgesia Patient anxiety with non-narcotic strategy Physician anxiety Same-day discharge POST-OP Scheduled Tylenol & Ibuprofen q6h (alternating) Same day discharge hrs post-discharge Phone follow up (independent health coach)

13 Outcome Measures Composite OBAS measure: Pain Vomiting Itching Sweating Freezing Dizziness Satisfaction with pain management

14 Results 61% patients: successfully avoided discharge narcotics 88% patients: high or very high overall satisfaction Unplanned contact with providers for pain management minimized No adverse events: Readmission Bleeding (with use of perioperative NSAIDs) Aspiration 3 Lehmann N, Joshi GP, Dirkmann D, Weiss M, Gulur P, Peters J, Eikermann M. Development and longitudinal validation of the overall benefit of analgesia score: a simple multidimensional quality assessment instrument. Br J Anaesth Oct;105(4):511-8.

15 Preoperative Counseling Feasible and Safe Low pain perception scores High patient satisfaction with MMA (88%) Most patients avoided opioid prescriptions (61%) PRE-OPERATIVE Single oral dose: Gabapentin mg Acetaminophen 1000 mg Meloxicam 7.5 mg INTRA-OPERATIVE Pre-incision local anesthetic injection Prudent use of inhalational/ IV agents Routine surgical technique POST-OPERATIVE Scheduled Acetaminophen & Ibuprofen every 6 hourly (alternating)

16 Study 2: Adoption of Multimodal Analgesia & Changes in Prescribing Practices Key question: In outpatient head and neck surgery, does institutional availability of MMA pathway influence: 1) Adherence to such pathways? 2) Frequency of opioid prescriptions at discharge? Thyroidectomy Parathyroidectomy

17 Methods Preoperative Counseling Same-day thyroid and parathyroid surgery (n=528) Optional MMA pathway available Retrospective data analyses (January 2015 to June 2017) PRE-OPERATIVE Single oral dose: Gabapentin mg Acetaminophen 1000 mg Meloxicam 7.5 mg Non-opioid post-operative analgesia Ibuprofen 600 mg PO q6h Acetaminophen 500 mg PO q6h INTRA-OPERATIVE Pre-incision local anesthetic injection Prudent use of inhalational/ IV agents Routine surgical technique Outcome metrics: Adherence to all components of MMA pathway Frequency of opioid prescriptions on discharge POST-OPERATIVE Scheduled Acetaminophen & Ibuprofen every 6 hourly (alternating)

18 Use of MMA protocol elements as % of total eligible patients annually Issuance of opioid prescriptions as % of total eligible patients annually Favorable outcomes Adherence to MMA pathway Frequency of opioid prescription on discharge Year p-value Adherence (to all 3 components of MMA), frequency, n (%) 0 (0.0) 106 (43.4) 142 (87.7%) < Opioid prescription upon discharge, frequency, n (%) 16 (13.1) 22 (9.0) 3 (1.9%) < Year of surgery 0 Likelihood of opioid prescription on discharge, OR (95% CI)* Ref ( ) 0.13 ( ) Opioid prescriptions Gabapentin Adherence NSAIDs Acetaminophen

19 Conclusion Non-opioid multimodal analgesia strategy in outpatient thyroid and parathyroid surgery is associated with: Reduced frequency of opioid prescriptions upon discharge Improved physician prescribing practices Adoption and adherence to pathway components Implications Template for actionable, effective, safe multimodal analgesia strategy Bridge between desire and ability to effect non-opioid based analgesia

20 Opioids, Multimodal Analgesia and We Getting started with MMA Study own institutional experience Use published guidelines and resources Find institutional champions and collaborators Create an institutional plan, execute & measure outcomes

21 Next steps: Expanded applications? Comparative effectiveness studies

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23 Head and Neck Surgical Oncology Angela Osmolak, MD Additional contributors: Department of Anesthesia, Nebraska Methodist Hospital Nursing and clinical teams at the Nebraska Methodist Hospital Mark D Agostino, MD Justin Oltman, BS Erik Interval, MD Brittany Kauffman, BSN Russell Smith, MD Thank you