International perioperative pain management approaches


Opioids were initially used for acute and cancer-related pain in the early 20th century. In a seminal campaign in 1996, the American Pain Society (APS) introduced “pain as the fifth vital sign” to address the issue of inadequate treatment of pain. Since then, opioid-class drugs were approved by the United States Food and Drug Administration (FDA) for pain management. Opioid therapy has hence been readily used internationally, not only for acute and cancer pain but also for chronic noncancer pain management. Worldwide consumption of opioids for pain management surged by seven folds since the 1990s with an overprescription of opioids for pain management in the recent decades contributing to an opioid abuse epidemic in the United States. ,

The Centers for Disease Control and Prevention estimated that there were approximately 450,000 death owing to opioid over-prescription, from 1999 to 2019. In 2018 alone, there were close to 15,000 deaths due to opioid overprescription, comprising 32% of the 47,000 opioid-related deaths in total—equivalent to 41 deaths per day in 2018.

A population-based statistical calculation of the total amount of opioid consumption per population of each country in 2019 illustrated that American and European countries, such as the United States and Germany, had an average consumption of narcotic drugs of 12,575–40,240 defined daily doses for statistical (S-DDD) purposes. This metric is defined as annual doses of opioids divided by 365 days, divided by the population of interest (in millions). , The consumption of opioids in Asian countries, in contrast, was low, ranging from 26 to 2409 S-DDD per million inhabitants per day. According to the Central Registry of Drug Abuse in Hong Kong, the total number of reported drug abusers has declined by 4% in 2018. Nevertheless, there was an increasing number of young drug abusers (aged up to 35 years old), comprising 35% of all reported abusers. Tables 10.1A and B illustrate an overview of the prevalence of opioid use per country population, the average opioid consumption, and deaths related to opioid overdose and opioid use worldwide. ,

Table 10.1A

Overview on prevalence, opioid consumption and deaths related to opioid use in Asian countries , .

Countries Bangladesh China India Japan Philippines Singapore South Korea Thailand Vietnam
Prevalence (%) of opioid use in 2017 (relative changes between 1990 and 2017) 0.51% (+3%) 1.11% (−3%) 0.53% (+8%) 0.92% (+8%) 0.65% (−4%) 0.91% (+5) 0.91% (+9%) 0.85% (+13%) 0.69% (+13%)
Death from opioid overdose (number of deaths in 2017) 1,438,000 15,075,000 6,120,000 457,000 455,000 11,000 84,000 608,000 791,000
Direct death from opioid use disorder in 2017. Death per 100,000 individuals (relatives changes between 1990 and 2017) 2.55 (−10%) 1.28 (−57%) 0.93 (+29%) 0.33 (+237%) 0.68 (−49%) 0.25 (+126%) 0.22 (−23%) 0.93 (+92%) 1.21 (+50%)
Average consumption of narcotic drugs a , in defined daily doses for statistical purposes (S-DDD) per million inhabitants per day (2015–17) 58 208 36 1413 26 577 2409 218 1883

a Drugs include buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone and others.

Table 10.1B

Overview on prevalence, opioid consumption and deaths related to opioid use in American, European and Oceanian countries , .

Countries Australia Brazil Canada Germany United Kingdom United States of America
Prevalence of opioid use in 2017 (%) and relative changes between 1990 and 2017 2.32% (+9%) 1.06% (+13%) 2.28% (+26) 0.88% (+15%) 1.66% (+13%) 3.45% (+46%)
Death from opioid overdose (number of deaths in 2017) 691,000 1,295,000 1,285,000 774,000 1,604,000 47,343,000
Direct death from opioid use disorder in 2017 death per 100,000 individuals (relative changes between 1990 and 2017) 4.05 (+83%) 0.98 (+116%) 4.95 (+258%) 2.06 (+27%) 4.23 (+191%) 18.75 (+802%)
Average consumption of narcotic drugs a , in defined daily doses for statistical purposes (S-DDD) per million inhabitants per day (2015–17) 15,282 500 26,029 28,862 12,575 40,240

a Drugs include buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone and others.

Motivation reviewing perioperative management in otolaryngology—head and neck surgery

Surgeons, after chronic pain physicians, were found to be the second most frequent prescribers of opioids. Almost every 4 out of 10 drug prescriptions for opioids were prescribed by surgeons. Moreover, 10% of patients who were opioid naïve became long-term opioid users after being given opioids for short-stay low-risk surgeries. Opioid naïve patients receiving postoperative opioid therapy were 44% more likely to become a long term opioid users in comparison to those who received nonopioid postoperative pain therapy. A cross-sectional study at the University of Pennsylvania Medical Center showed a 6% prevalence rate of opioid prescription in otolaryngology-head and neck surgery (OHNS). Inevitably, OHNS surgeons must take accountability for “opioid diversion,” defined as nonmedical use of legally prescribed opioids, resulting in opioid misuse and overdose-related deaths.

In this chapter, we will review international perioperative pain management approaches in OHNS. A preliminary search in MEDLINE was performed with combinations of the terms opioids and otorhinolaryngology to evaluate the relevant abstracts and establish the keywords in the main search. Relevant publications were identified through MEDLINE (1946 to April 2021), EMBASE (April 2021 via Ovid SP), and Google Scholar. The search used the following subject headings and keywords: opioid, otolaryngology, otorhinolaryngology, ear nose and throat, septoplasty, rhinoplasty, tonsillectomy, sinus surgery, ear surgery, adenoidectomy, perioperative pain, perioperative analgesia, enhanced recovery after surgery, and ERAS.

Overview of perioperative pain management globally

While surgery aims to remove pathological insults from the body, to repair and restore function, it creates another form of injury to the body requiring a subsequent healing process and rehabilitation. Surgical trauma has been shown to affect the immune response and thus hinder recovery, in addition to anesthetic effects, physical and psychological stress, and postoperative pain. Beilin et al. highlighted the effects of postoperative pain optimization on attenuating surgery-associated immunosuppression in 2003. Therefore, in the past two decades, activists worldwide proposed guidelines and protocols for perioperative pain management. In general, perioperative pain management is a structural pathway with both pharmacological and nonpharmacological treatments involving different healthcare parties including surgeons, nurses, anesthetists, pain specialists, or intensive care physicians before, during, and after the operative procedures. The APS and the American Society of Anesthesiologists compiled a guideline with evidence-based recommendations on perioperative pain management. Similarly, the British and Australian counterparts published perioperative care guidelines such as the National Institute for Health and Care Excellence reviews for managing acute postoperative pain. , The principles of perioperative pain management include preoperative education, perioperative planning, application of different pharmacological and nonpharmacological modalities, organizational policies and procedures, and outpatient care planning.

Preoperative counseling and education of patients and caregivers

It is recommended that patient-oriented, individually tailored education on options of postoperative pain therapy are provided to patients and their caregivers. They should be counseled on the expectation of postoperative pain and reassured the pain would be monitored and optimally controlled with pain-relieving therapy. Active engagement of patients and caregivers for pain management reduces anxiety and corrects potential misconceptions about pain control therapy. Safe use of opioids, proper storage, and proper disposal should be emphasized to avoid opioid diversion.

Preoperative high-risk assessment

Preoperative evaluation should review medical comorbidities; current consumption of analgesics, opioids, psychiatric and anxiolytics drugs; social history including alcohol and substance abuse; and biopsychosocial assessment for pain. Any new prescriptions of opioids, benzodiazepines, sedative-hypnotics, anxiolytics, and central nervous systems depressants should be avoided before surgery. It is particularly important in complex pain patients to avoid potential chronic opioid dependence after surgery. If a high-risk case is anticipated, the patient should be referred to pain specialists for assessment.

Intraoperative preemptive analgesia

Studies have shown ongoing nociceptive stimuli increase the excitability of central nociceptive neurons, leading to central sensitization, lowering the activation threshold for pain. , Hence, the previously nonpainful low-intensity stimuli generates a painful sensation across the area of surgically injured tissue. Preemptive analgesia hypothesizes that preoperative pain therapy before “preincision” stage may facilitate postoperative pain control when compared with the same analgesia given after the surgery. The use of multimodal analgesia, for instance, paracetamol, NSAIDs such as celecoxib or ketorolac, gabapentin, or pregabalin—when given preoperatively—reduces postoperative pain scores. , , , While opioid-sparing perioperative therapy is suggested in opioid naïve patients, appropriate intraoperative opioid dosing should be administered in known chronic opioid-using patients to avoid acute withdrawal postoperatively.

Postoperative pain assessment

Postoperative pain should be optimized before leaving the postoperative recovery bay to the ward or intensive care unit. A validated pain assessment tool is recommended to monitor the response to pain management and to adjust the treatment plan accordingly. Examples of validated pain intensity assessment scales include visual analog scales, numeric or verbal rating scales. In pediatric cases with nonverbal expression, the face, legs, arms, cry, and consolability five-item scale (each item scoring 0–2) is recommended for postoperative pain assessment during hospitalization. ,

Postoperative multimodal analgesia and adverse effect monitoring

While single opioid use for analgesia could achieve postoperative pain relief, it has also been shown to have significant postoperative adverse reactions such as emesis and respiratory depression. Systemic reviews recommend a multimodal analgesia regimen for postoperative pain control. The European Society of Regional Anesthesia and Pain Therapy has proposed a procedure-specific postoperative pain management (PROSPECT) initiative with evidence-based recommendations for the treatment of pain across various types of operations.

When postoperative pain control cannot be achieved by nonopioid analgesics such as paracetamol or NSAIDs, immediate-release and short-acting opioids should be offered to provide adequate pain relief. , Also, the oral route is preferred over intramuscular and intravenous routes for the administration of analgesics when the patients are able to tolerate oral intake. , , If a parenteral route is needed, intravenous patient-controlled analgesia is recommended for systemic pain control. Nevertheless, routine basal infusion of opioids should be avoided in opioid-naïve adults. , , When the patient receives opioid therapy, it is essential to monitor vital signs, level of consciousness, and respiratory status. Common side effects of opioids such as nausea and vomiting, and opioid-related constipation should not be overlooked. Additionally, the red flag warnings of opioid overdose—including excessive sedation, respiratory depression, and pinpoint sized pupils—should be recognized early and an opioid antagonist made promptly available.

Pain specialist consultation in high-risk cases

Some patients, in particular those who are opioid-tolerant, have substance abuse histories, or alcoholism, have a poor tolerance to postoperative pain despite the use of multimodal analgesia and opioids. It is recommended in these cases to refer or consult a pain specialist for interventional treatment.

Transitioning to outpatient care

Recognizing the problem of illicit use of medical prescribed opioids, the Washington State Agency Medical Directors’ Group (AMDG) provided a guideline of postoperative pain therapy on discharge depending on the extent of the surgery and expected progression of pain. AMDG recommended the use of multimodal analgesia with a plan for opioid tapering according to the length of expected recovery. If minor surgery is performed and there is an expectation of minimal postoperative pain, it is suggested to discharge the patients with acetaminophen or NSAIDs only, or with a two to 3 day supply of short-acting opioids. Whether a patient is expected to have rapid recovery (Type 1), medium-term recovery (Type 2), or longer-term recovery (Type 3), acetaminophen and NSAIDs are still recommended as first-line therapy in postoperatively. In cases of severe pain, short-acting opioids should be prescribed with less than 3 day’s quantity, 7 day’s quantity, and 14 day’s quantity respectively for type 1, type 2, and type 3 recoveries. For major surgeries, surgeons are responsible and are advised to taper the opioid use within 6 weeks.

Similarly, other guidelines have suggested opioid-sparing therapy or nonpharmacological therapy as first-line treatment and judicious use of opioid therapy for severe postoperative pain. , , The emphasis of education on opioid dependence, the need of discontinuing opioid consumption after resolution of pain, prevention of opioid diversion, safe storage, and disposal of unused opioids are highlighted. Nursing consultation for patients and caregivers upon discharge, written instructions of recommended opioid dose, opioid supply and duration of use, and patient leaflets for opioid storage and disposal help to reinforce the cautious use of opioids after discharge. ,

In pediatric cases, education to parents and caregivers on the appropriate use of analgesia is a large determinant of successful postoperative pain control in children. Parents’ postoperative pain measure is recommended for parents to assess the severity of pain experienced by their children at home.

Perioperative pain management in general otolaryngology—head and neck surgery procedures globally

Despite recommendations provided in the aforementioned guidelines describing the role of postoperative opioids, there is rarely clear guidance for perioperative pain management in procedures such as tonsillectomy, nasal surgery, and major head and neck surgery.


Tonsillectomy is one of the most painful surgical procedures frequently performed by otolaryngologists. The PROSPECT Initiative provides evidence-based recommendations for perioperative pain management after tonsillectomy. There is strong evidence that NSAIDs should be administered preoperatively or intraoperatively and continued postoperatively. A single dose of intravenous dexamethasone given intraoperatively is highly recommended for postoperative analgesia and alleviation of postoperative nausea and vomiting. A Swedish group developed a national guideline for pediatric tonsillectomy-related pain management in 2012 and evaluated the effects in 2015. Table 10.2 compares various global recommendations for perioperative pain management for tonsillectomies in both adult and pediatric groups.

Table 10.2

Compares various analgesic protocols for tonsillectomy globally.

Preoperative Intraoperative Postoperative Discharge

  • Combinations of paracetamol and NSAIDs at pre- or intraoperative period

  • A single intraoperative dose of IV dexamethasone

  • Paracetamol (Grade D)

  • NSAIDs (Grade A)

  • Opioids for rescue (Grade D)

Swedish guidelines

  • Paracetamol 40 mg/kg

  • Clonidine 2-3ug/kg

  • Betamethasone 0.2 mg/kg, max 8 mg

  • Diclofenac 1 mg/kg IV/PR or

  • Ibuprofen 5–7 mg/kg PR or

  • IV parecoxib 0.5 mg/kg or

  • LA bupivacaine 5 mg/mL to wound 5 min

  • IV paracetamol

  • Clonidine

  • Opioid titration

  • IV ondansetron 0.1 mg/kg, promethazine 0.1 mg/kg or droperidol 30ug/kg or

  • Regular panadol + NSAIDs/celecoxib for 3 days

  • Regular NSAIDs and paracetamol 5–8 days after tonsillectomy

  • Single dose clonidine, opioid (morphine/oxycodone) PRN

French: SFORL

  • Dexamethasone (level 1 evidence)

  • Tramadol (1 mg/kg Q6H with vigilant use)

  • Paracetamol (level 1 and 2 evidence)

  • Ibuprofen 5 mg/kg Q6H (level 1 and level 4 evidence)

  • Paracetamol

  • Ibuprofen or tramadol

Australian: ANZCA

  • Gabapentin (10–20 mg/kg)

  • Dexamethasone or

  • Peritonsillar infiltration of tramadol 2 mg/kg

  • Paracetamol 15 mg/kg PO + diclofenac 1 mg/kg PO or

  • Paracetamol 15 mg/kg PO + Ibuprofen 4.5 mg/kg or

  • Paracetamol 30 mg/kg PO

Hong Kong: Prince of Wales hospital

  • Paracetamol 15–30 mg/kg PO Q4H

  • Ibuprofen 20 mg/kg/day PO TDS

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Feb 19, 2022 | Posted by in OTOLARYNGOLOGY | Comments Off on International perioperative pain management approaches
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