Multimodal Pain Protocol After Head and Neck Surgery in the Context of the Current Opioid Crisis

Background: The United States is in the midst of a public health crisis of prescription opioid addiction, abuse and overdose. Use of narcotic medication in the post-surgical setting may contribute to the problem. Multimodal analgesic plans have the potential to decrease narcotic requirements in patients after surgery; however, there is little prospective data to show efficacy in Head and Neck (H&N) surgery patients. Methods: An IRB approved, quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all H&N surgery patients at a tertiary referral center. The protocol was implemented November 2017 and post-protocol data from January 2018 to May 2018 were compared to pre-protocol data from May 2017 to October 2017. Data were abstracted from the electronic health records as well as through pre-operative and post-operative surveys. Average pain scores and opioid use in Morphine Milligram Equivalents (MME) before and after protocol implementation were compared. Results: One-hundred-and-five post-protocol patients were compared to 167 pre-protocol patients. The adjusted median MME in the first 24 hours after surgery decreased significantly from 93.7mg to 58.6mg (p=0.026) with protocol implementation. When averaged over the length of stay (MME/HD), there was no significant change between the pre and post protocol cohort (57.9mg vs 46.8mg, p=0.211) The average pain score immediately after surgery was 3.6 and on the day of discharge was 2.7; neither measure changed with protocol implementation. Conclusion: Our multimodal analgesia plan reduced narcotic use immediately after surgery but not over the course of hospitalization. There was no difference in average reported pain scores. This study shows that implementation of a multimodal narcotic-sparing analgesia plan after H&N surgery is feasible. Future studies will need to further refine the optimal analgesia plan, optimize pain regimens for various patient characteristics and assess the long-term efficacy, safety and cost of such regimens.Master of Public Healt