Introduction
As a result of the ongoing public health crisis of opioid addiction in the United States, increased focus and scrutiny have been placed on physicians’ pain management practices. Moreover, postoperative opioid prescribing practices after routine surgical procedures are often not standardized and can vary widely. While the current epidemic of opioid addiction is multifactorial and cannot solely be ascribed to surgeons’ prescribing practices, the impact of conscientious and evidence-based perioperative pain management has certainly become clearer and more evident. However, reducing opioid prescribing is only one piece of a larger puzzle. Effective perioperative pain management is multifaceted, and, as with many other aspects of surgical practice, it is most successful when implemented systematically. To that end, this chapter will discuss several key components of a systems-based approach for perioperative pain management in otolaryngology including preoperative pain management assessment and education, current best evidence for perioperative pain management strategies, and incorporating pain management into successful enhanced surgical recovery (ERAS) processes.
Why a systems-based approach to perioperative pain management?
A systematic or systems-based approach to healthcare is an evolving concept that has gained popularity and traction in recent years. However, the idea that solutions to complex problems are multifaceted and interconnected is far from novel. In fact, it can be traced as far back as the philosopher Aristotle who famously remarked that the whole is greater than the sum of its parts . This simple yet insightful observation is especially pertinent to surgical practice where fostering a strong team dynamic is foundational. However, translating this abstract concept into more defined, systems-based approaches is challenging. While a full discussion of the theory and nuances of systems-based healthcare delivery is beyond the scope of this chapter, it is important for clinicians to have a general understanding of how this concept relates to the ongoing conversations on how to improve current perioperative pain management practices.
Proponents of a systematic approach to healthcare delivery cite similarities between medicine and other “high-risk” industries such as commercial aviation and petroleum engineering. While these are admittedly imperfect analogies to surgical practice, there is a common theme—namely mitigating and managing potential risks and continuously pursuing higher-level goals of safety and quality. In response to reports published by the Institute of Medicine detailing disparities in quality and patient safety, the President’s Council of Advisors on Science and Technology (PCAST) recommended that a systems [based] approach be promoted at all levels of the American healthcare system. The PCAST report went on to recommend employing key principles of systems engineering—i.e., integrating pertinent disciplines, understanding the operational environment, and utilizing available metrics to evaluate quality and performance—to improve the quality and efficiency of healthcare delivery. Although germaine in theory, applying these principles to actual clinical practice has proven challenging. Critics of systems-based healthcare argue that such approaches lead to overreliance on standardized, formulaic care, reduce clinician autonomy, and shift responsibility and accountability for errors away from individuals and onto a faceless “system.” While these concerns are certainly valid, as Dekker and Levenson observe, such reservations often result from a misunderstanding of what is meant by a systems-based approach. Far from simply creating standardized checklists, the goals of systems-based healthcare are to recognize the inherent linkages within a given healthcare environment and to design evidence-based frameworks that promote synergy, collaboration, and accountability. Successful real-world examples of systems-based approaches to healthcare delivery include the Surviving Sepsis Campaign to promote early identification and directed therapy for sepsis in critical care patients, employing information technology resources to track and support evidence-based care in chronic health conditions, and navigation programs to improve access and coordination of complex, multidisciplinary care for cancer patients.
The consequences of the historically fragmented and disparate approaches to postoperative pain management have been rendered even more salient by the ongoing opioid addiction crisis. As with other surgical specialties, significant variations in pain management and opioid-prescribing practices have been repeatedly demonstrated among otolaryngologists—head and neck surgeons performing common procedures. A retrospective review of five common outpatient surgical procedures demonstrated significant variations in the total amounts of opioids prescribed with the widest variance seen in patients undergoing thyroidectomy. Similarly, a recent survey study demonstrated divergent pain management practices among a cohort of endocrine-focused head and neck surgeons and a heavy reliance on postoperative opioids following outpatient thyroid and parathyroid surgery. These studies are just a few examples among many with similar results that speak to the scope and scale of the problem.
The reasons for such varying perioperative pain management practices are myriad and include a historical lack of evidence-based recommendations, practice variations as a result of training and location, disparate expectations between providers and patients, and shifting societal knowledge and priorities. Moreover, this problem goes beyond simply overprescribing and overreliance on opioids. A complex problem like this requires innovative solutions, and we need a systematic review and revamping of how we approach and manage perioperative pain. Therefore, shifting focus from simply trying to alter individual clinicians’ behavior to pursuing systems-based approaches has so much potential benefit. As Dekker and Leveson aptly observe :
It is unrealistic to believe that [physician] behavior is not affected by the context in which it occurs … The goal of a systems approach is … to design a system in which individual responsibility and competence can effectively create desired outcomes.
With this rationale in mind, surgeons are well advised to work within their respective institutions and healthcare systems to construct clinical care pathways that promote and support perioperative pain management. In the following sections, we will discuss the rationale and available evidence for the primary components of a systematic approach to perioperative pain management including preoperative patient-specific pain assessment, surgeon-performed pain management counseling and education, multimodality pain regimens, and enhanced recovery protocols as a comprehensive, systematic approach to perioperative pain management.
Preoperative pain assessment and counseling
A systematic, comprehensive approach to perioperative pain management spans the continuum of the surgical encounter and begins at the initial preoperative consultation. To promote successful postoperative outcomes, surgeons are well accustomed to assessing patients’ underlying medical risk factors and providing educative counseling regarding surgical complications and expectations. Similarly, evaluating patient-specific risk factors for perioperative pain and delivering focused counseling on pain management risks and expectations are important elements of the preoperative consultation. Just as failing to recognize an underlying cardiac or hematologic disorder increases the risk of serious surgical complications, failing to appreciate patients’ unique pain management requirements and indiscriminate prescribing of opioid medications can have significant, negative consequences. As evidence, it has been reported that up to 20% of people suffering from opioid addiction were initially exposed to opiates via legitimately obtained prescriptions. Even more alarming, a recent large-scale study of opioid-naïve patients found that those prescribed opioids for even short-term management of acute postoperative pain experience a 44% relative risk of long-term opioid use, and as many as 10% of those patients may still be taking an opioid medication at 12 months or beyond after surgery. Thus, the potential positive or detrimental impacts of perioperative pain management practices cannot be overstated.
Preoperative pain risk assessment
In 1978, The International Association for the Study of Pain (IASP) provided one of the first consensus definitions of pain as a negative experience associated with actual or potential tissue damage. However, to better articulate the complex, multifaceted nature of pain, the IASP recently revised its decades-old definition. The updated definition describes pain as, “an unpleasant sensory and emotional experience associated with, or resembling that associated with , actual or potential tissue damage. ” In essence, this updated definition recognizes that pain is a personal experience that is impacted by multiple variables (i.e., biological, sociologic, psychologic, etc.) beyond the apparent nociceptive stimuli. Surgeons should recognize there is no uniform perioperative pain experience for patients and, as a result, there is not a one-size-fits-all approach to perioperative pain management. Patients’ postoperative pain management outcomes are impacted by several patient specific-variables, and the astute clinician should be proactive in assessing for and gaining a clear understanding of these factors well before the patient ever enters the operating room.
Several patient-specific factors have been identified that can portend an increased risk of higher postoperative pain levels and potentially higher opioid consumption. These include chronic or preexisting pain conditions, preoperative opioid use, prior postoperative painful experiences, inappropriate expectations or anxiety regarding proposed surgery, concomitant psychological issues (e.g., generalized anxiety disorder, major depressive disorder, etc.), and preexisting functional pain conditions (e.g., fibromyalgia). Within the otolaryngology literature, independent factors that have clearly been identified in patients undergoing outpatient head and neck surgery are age less than 45 years and prior use of opioid medications. Other factors that have been suggested include socioeconomic status, chronic medical conditions, history of tobacco or alcohol abuse, and even preoperative use of common nonopioid prescription medications—for example, benzodiazepines, selective serotonin reuptake inhibitors, and angiotensive converting enzyme inhibitors. , As part of the preoperative assessment, surgeons should proactively screen for patient-specific factors and counsel patients on postoperative pain expectations and developing a pain management plan.
Patient-centered perioperative pain management counseling
Physician–patient communication is a crucial component of effective healthcare delivery. While patient-centered health management education is well-established in other clinical conditions (e.g., diabetes), its value and utility in supporting efforts to reduce opioid consumption and improve perioperative pain outcomes are relatively novel and emerging concepts. However, the rationale and theoretical benefits of patient education certainly make intuitive sense as part of a systematic approach to perioperative pain management.
Sugai et al. provided one of the earliest studies objectively evaluating the impact of surgeon-performed pain education on postoperative pain outcomes. In their study, 90% of the experimental cohort—which received oral and written educational materials emphasizing the benefits, risks, and rationale of multimodality nonopioid versus opioid postoperative pain management—subsequently declined a postoperative opioid prescription following outpatient cosmetic procedures. Similarly, a recent single-institution study of orthopedic trauma patients found that those patients who were specifically counseled preoperatively regarding expected pain levels and duration of postoperative opiate use were significantly more likely to have stopped taking opioid medications by postoperative week 6 versus those receiving no such counseling. Incorporating pain expectation and management counseling has been demonstrated to have similarly positive results in head and neck surgery. Shindo and colleagues demonstrated that clinician-performed counseling focused on pain expectations and multimodality pain management strategies is a key component in programmatic efforts to reduce unnecessary postoperative opioid use while maximizing postoperative pain outcomes.
Selecting an appropriate setting can be an equally important component of effective pain management counseling. From the patient’s perspective, the preoperative office visit is an ideal setting for a conversation given its privacy and personalized context. While preoperative pain education and counseling can be composed of different topics, in general it is recommended that it at least focus on assessing past experiences with medical procedures and pain control, understanding past usage and issues with analgesics, and ascertaining patients’ impressions and prior experiences with opioid medications. Once an understanding of the patient’s unique situation and pain management expectations has been established, the surgeon can better outline the anticipated perioperative pain management approach. It is important to recognize the understandable consternation that can result from the anticipation of postoperative pain. To that end, effective preoperative education should also provide patients with a clear understanding that some measure of mild, manageable pain is expected and is part of the normal, uncomplicated postoperative healing process. Additionally, surgeons should highlight the proven efficacy of alternative pain management interventions (e.g., nonopioid medications, cool compresses, throat lozenges, etc.) while also clearly communicating that the proposed regimen can be appropriately tailored based on the patient’s specific postoperative pain experience. To promote consistency and efficacy clinicians should consider integrating into their preoperative assessment of factors that may influence postoperative pain management, which can be in the form of a checklist, and counseling regarding expectations and plans for managing postoperative pain. An example of a pain assessment and counseling reference tool is provided in Fig. 11.1 .
In summary, a successful systems-based approach to perioperative pain management begins at the initial preoperative encounter with both an assessment of patient- specific pain risk factors and a clinician-lead discussion of pain management expectations. These exercises can truly set the tone and tenor of patients’ subsequent postoperative pain experience. While clinicians can certainly modify the preoperative educational discussion to suit the needs of their patients and practice patterns, it should at minimum include the following topics: (1) accurate description of typical, expected postoperative discomfort; (2) reassurance that some pain is normal in the postoperative recovery period; (3) explaining the benefits and merits of nonopioid multimodality pain management; (4) discussing the risks of opioids and rationale of limiting their use in the postoperative period; and (5) describing processes to respond to patients’ concerns about postoperative pain and to adjust their pain management as needed. The fundamental goals of this important physician–patient communication are to set realistic, up-front expectations regarding postoperative pain and its management, to promote patients’ confidence in and acceptance of nonopioid, multimodality pain regimens, and to enable patients to feel more empowered and involved in their perioperative pain management experiences.
Perioperative multimodality pain management
As with many other surgical specialties, opioids have traditionally been a cornerstone of perioperative pain management in otolaryngology. As evidenced by several recent survey studies, there has been an overreliance on opioid medications across the spectrum of otolaryngologic procedures including endoscopic sinus surgery, facial plastic surgery, pediatric otolaryngology, and head and neck surgery. Several reasons may underscore this including the potent efficacy of opioids in managing acute pain, surgeons’ relative familiarity and experience with their use, and conventional hesitancy to using alternative medications (e.g., NSAIDs) due to potential perioperative complications such as postoperative hemorrhage. However, in light of contemporaneous evidence demonstrating both excessive amounts of prescribed opioids and the risk of secondary opioid addiction following even short-term postoperative use, increased interest and academic focus have been placed on the feasibility and utility of multimodality pain regimens that employ synergistic combinations of nonopioid analgesics and adjunctive interventions. The dual goals of this shifting paradigm are to effectively manage perioperative pain while reducing (or in some cases eliminating) the need for opioid medications.
Preoperative pain management
Effective multimodality pain management begins in the preoperative phase of care before the patient has experienced any nociceptive stimuli. Beneficial outcomes have been described with single-agent as well as combinatory use of several nonopioid medications—namely acetaminophen, gabapentinoids, and nonsteroidal antiinflammatory drugs (NSAIDs). Otolaryngologists should be familiar with the primary medications available for preoperative administration as well as their associated risks and benefits.
Acetaminophen (APAP)—also known as N -acetyl para-aminophenol or paracetamol—is a well-established and widely available analgesic with numerous applications. Although the primary mechanism of action remains unclear, its analgesic properties are thought to be the result of inhibition of the cyclooxygenase (COX) pathway within the central nervous system. However, as it does not directly bind to either COX-1 or COX-2, APAP does not exhibit antiplatelet activity which makes it particularly attractive for preoperative use. Additionally, APAP can be administered either orally or intravenously. The intravenous form of APAP is relatively newer—as the FDA only approved it for use in 2010. The potential benefits of preoperative IV APAP include lower reported postoperative pain levels and decreased opioid requirements, , reduced incidence of postoperative nausea/vomiting (PONV), and shorter postoperative hospital stay. , Considering these benefits, it is nonetheless important to note that IV APAP is considerably more expensive than oral formulation. The efficacy versus cost-effectiveness of preoperative IV versus PO APAP has been studied in a recent randomized control trial that demonstrated no significant differences in postoperative pain control or PONV with IV APAP. While many patients can be adequately managed with PO APAP, the IV formulation may have specific benefits in select circumstances such as patients unable to tolerate oral medications, those with hepatic insufficiency, or those with gastrointestinal issues that would compromise parenteral medication uptake. A single preoperative dose of 1000 mg of APAP is reasonable and efficacious for a majority of otolaryngologic procedures.
NSAIDs have also shown promise in the preoperative setting. The primary mechanism of action of this class of analgesics is direct inhibition of COX-mediated inflammatory pathways. While this makes them efficacious in the management of acute postoperative pain, their use in the preoperative setting has historically been limited due to concerns regarding their antiplatelet activity. As a result, data on the safety and efficacy of preoperative NSAIDs for head and neck procedures are somewhat limited and heterogeneous compared to APAP. With respect to postoperative pain and opioid requirements, preoperative dosing of intravenous ibuprofen was shown to be superior to APAP in patients undergoing odontogenic procedures. Preoperative use of NSAIDs in pediatric tonsillectomy has been shown to be effective but, based on a recently published meta-analysis, the data on the risk of secondary posttonsillectomy hemorrhage is equivocal due to lack of robust, prospective randomized studies. Regarding concerns of intraoperative and postoperative bleeding, a recent report on the use of preoperative ketorolac in endoscopic sinus surgery showed no increase in intraoperative or postoperative bleeding compared to placebo. Alternatively, selective COX-2 inhibitors (coxibs) have been advocated for postoperative pain due to their reduced effects on normal coagulation. Preoperative administration of both classes of NSAIDs has been shown to have benefits both in reducing postoperative pain levels and decreasing patients’ opioid requirements in the first 24 h after surgery.
Lastly, gabapentinoid agents such as gabapentin and pregabalin have gained popularity as adjunctive analgesics. Gabapentinoids are derivatives of the inhibitory neurotransmitter γ-aminobutyric acid and are primarily used in the prevention of epileptic seizures and the management of anxiety disorders. As analgesics, these medications have shown benefits in the treatment of pain from diabetic neuropathy and postherpetic neuralgia. As they also have a low overall abuse potential, their use has expanded to off-label applications such as acute perioperative pain. Recent studies have suggested positive albeit contradictory results in the preoperative use of gabapentin and pregabalin. , In addition, suggested dosages can vary widely from 150 to 1200 mg and untoward sequela such as blurred vision, somnolence, dizziness, and mood disturbances have been reported. , Specifically, regarding head and neck applications, a meta-analysis performed by Arumugam and colleagues suggested that preoperative gabapentin may reduce cumulative postoperative opioid requirements following thyroidectomy. Lastly, clinicians should be aware of recent FDA warnings regarding potential respiratory and neurologic depression and should also counsel patients about the off-label use of gabapentinoids for perioperative pain.
Based on currently available evidence in the otolaryngology literature, multimodality regimens appear to be superior to single-agent therapy for preoperative analgesia. Oltman et al. described a standardized regimen of meloxicam, acetaminophen, and gabapentin in patients undergoing outpatient thyroid, parathyroid, and parotid surgery. The authors demonstrated low resting and peak pain scores, and 60% of patients completely avoided postoperative opioids. Moreover, there were no treatment-specific complications and 90% of patients reported high-to-very-high levels of satisfaction with their perioperative pain management experience. A summary of commonly used preoperative analgesic agents, their typical dosing, and potential contraindications is provided in Table 11.1 .
