Optimizing Outpatient Pain Management After Thyroid and Parathyroid Surgery: A Two-Institution Experience

Abstract

Background Thyroidectomy and parathyroidectomy are the most commonly performed endocrine operations, and increasingly are completed on a same-day basis. Little data exists regarding the outpatient post-operative pain requirement of these patients. We aimed to describe the outpatient narcotic medication needs for patients undergoing thyroid and parathyroid surgery, and to identify predictors of higher requirement. Method We examined patients undergoing thyroid and parathyroid surgery at two large academic institutions from January1-May 30, 2014. Prospective data was collected on pain scores and the oral morphine equivalents (OMEQ) taken by these patients by their post-operative visit. Results 313 adult patients underwent thyroidectomy or parathyroidectomy during the study period. 83% of patients took 10 or fewer OMEQ, and 93% took 20 or fewer OMEQ. Patients who took more than 10 OMEQ were younger (p<0.001) and reported significantly higher overall mean pain scores at their post-operative visit (p<0.001) than patients who took fewer than 10 OMEQ. A multivariate model was constructed on pre and intraoperative factors that may predict usage of greater than 10 OMEQ post-operatively. Age < 45 years (p=0.002), previous narcotic use (p=0.037) and whether parathyroid or thyroid surgery was performed (p=0.003) independently predicted the use of more than 10 OMEQ after surgery. A subgroup analysis was then performed on thyroidectomy only patients. Conclusion 93% of patients undergoing thyroidectomy and parathyroidectomy require 20 or fewer OMEQ by their post-operative visit. We therefore recommend these patients be discharged with 20 oral morphine equivalents, both to minimize waste and increase patient safety.

Optimizing Opioid-Prescribing Practices After Parathyroidectomy

“…Our study results, in line to what is reported in the literature, show that higher reported maximum and last pain scores before discharge are associated with higher postoperative opioid need. 13 Interestingly, our study did not find an association between opioid consumption and other factors that are known to predict opioid need including patients' age, sex, and history of depression or anxiety. 12,14,15 Depression or anxiety rates were higher in top opioid users compared to standard users, but the difference was not statistically significant.…”

“…Another study assessed opioid requirement after thyroidectomy and parathyroidectomy and found no difference between unilateral and bilateral neck exploration but patients undergoing thyroidectomy required more opioid compared to parathyroidectomy. 13 However, 93% of all patients included in that study required less than 20 MME which is equivalent to 2.6 tablets of 5 mg oxycodone. 13 Thus, we recommend prescribing nonopioid analgesic for patients undergoing these procedures as their opioid needs do not justify prescriptions and our results suggest that over 95% of them did not dispose the leftover opioids.…”

Randomized clinical trial of platysma muscle suture versus no suture for wound closure after thyroid surgery

“…Postoperative pain after thyroid surgery is normally moderate and limited to the first few days, usually necessitating pain medication with non‐opioid analgesics. Some patients need rescue medication with opioids in this early period, which potentially delays hospital discharge.…”

Evaluating contemporary pain management practices in thyroid and parathyroid surgery: A national survey of head and neck endocrine surgeons

“…Beyond divergent prescribing patterns, it is becoming quite apparent that the vast majority of post‐thyroidectomy and parathyroidectomy patients are likely receiving total amounts of opioids far in excess of their pain control needs. Lou et al prospectively analyzed their institutional prescribing patterns and found that despite being prescribed up to 120 MME, the pain requirements of 93% of patients were adequately addressed with <20 MME . Another single institution study revealed that post‐thyroidectomy patients were routinely prescribed enough opioids to satisfy regular use for a 14‐day duration despite a mean discharge pain score of 3 on a standard 0‐10 scale .…”

“…Next, we recognize that the use of ordinal ranges of prescribed tablets may have resulted in decreased precision in fully assessing the true amounts of opioids typically prescribed by our surveyed cohort, and this is perhaps the primary limitation of this study. These ranges were selected based on commonly reported amounts of prescribed tablets, and the corresponding survey question was structured to simplify and streamline the survey to encourage a higher overall RR. That being said, this approach did result in a somewhat arbitrary grouping that might overstate the variations and mischaracterize the more subtle nuances in opioid‐prescribing patterns among our cohort.…”