DOI: https://doi.org/10.21203/rs.3.rs-2137130/v1
Thyroid surgery is one of the most common surgical procedures with typical mild-to-moderate pain postoperatively. Thus, postoperative pain control is clearly of primary concern to patients, as well as surgeons. The unnecessary use of opioid analgesics is a well-known contributing factor to opioid addiction. Recently, experts from the Endocrine Surgery Section of the American Head and Neck Society released a consensus to limit the use of opioid medications as the first-line pain medications after head and neck or endocrine procedures. Thus, this study aimed to evaluate the postoperative pain control medication prescription practices of head and neck or endocrine surgeons for patients who underwent thyroid surgery.
This study retrospectively reviewed the charts of 105 adult patients who underwent thyroid surgery (total thyroidectomy, thyroid lobectomy, or subtotal thyroidectomy) by head and neck or endocrine surgeons. The type of prescribed pain medication at hospital discharge postoperatively was then retrieved from each patient’s discharge medication list. Descriptive statistics mean, standard deviations, frequencies, and percentages were computed, while the Chi-square test was applied to measure the significant differences among variables at a 5.00% significant level.
An outpatient oral opioid, in the form combining paracetamol and codeine, was prescribed for 62 (59%) patients whereas 43 (41%) were discharged on paracetamol only.
The use of opioids is the practice pattern for pain management among some head and neck or endocrine surgeons despite emerging evidence that supports the use of non-opioid and other alternative analgesic strategies in outpatient thyroid and parathyroid surgery. Further research and quality improvement interventions should be geared towards leading all health professionals to appropriate prescription practices to improve patient safety and reduce unnecessary opioid prescriptions.
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”(1). Surgery triggers a wide range of responses in the pain matrix, including pain pathway sensitizations in the peripheral and central nervous systems (2).
Postoperative pain management and control are clearly of primary concern to patients, as well as surgeons, to minimize the potential adverse effects associated with the physiological effects of surgery-induced pain. Poor postoperative pain control and increased opioid intake can be predicted by factors such as young age, female gender, smoking, depression, anxiety, use of preoperative analgesia, and type of surgery (major, emergency, or abdominal) (3).
Several procedures or treatments, such as local anesthetic infiltration, non-opioids, or opioids, were employed for postoperative analgesia. Non-opioids are becoming more widely used in postoperative pain management, either alone or in combination with other analgesics (4).
Non-opioid analgesics are classified as acid and non-acid antipyretic drugs. Non-acidic antipyretics (paracetamol and dipyrone) have analgesic and antipyretic properties but are devoid of anti-inflammatory properties while non-steroidal anti-inflammatory drugs (NSAIDs) are acidic antipyretic drugs that extend the bleeding time and were not recommended, historically, for use after thyroid surgery due to the risk of postoperative bleeding (5, 6). However, recent evidence has shown no significant increased risk of postoperative hematoma (7).
Opioids are classified into illicit opioids, such as heroin, and prescription opioids used as pain relievers, such as oxycodone, codeine, morphine, etc. (8). Sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression are well-known side effects of opioids (9). Patients typically experience mild-to-moderate pain after thyroid surgery (10, 11). However, perioperative analgesia strategies after outpatient head and neck surgery (including thyroid surgery) often rely on opioid administration. Additionally, opioid abuse and dependence were significant, wherein 5–7% of patients continue to use opioid medication for up to 6 months after head and neck or endocrine surgery (12, 13). Moreover, recent western studies indicate that legally prescribed opioids have resulted in a significantly increased number of deaths over the past two decades (14, 15). Shifting to multimodal pain control methods was incorporated to improve the postoperative analgesia quality and minimize opioid use (4, 16). Combination of paracetamol, ibuprofen, and tramadol are example of a multi-modality postoperative pain management regimen (17).
Postoperative pain management practices vary among surgeons worldwide and data-driven evidence to uncover that in Saudi Arabia is lacking; thus, this study aims to assess the current prescription practices as an evidence-based first step to help professionals work toward systematic reductions in opioid prescriptions for patients undergoing thyroid surgery in this part of the world.
This retrospective cohort study was conducted on all opioid-naive adult patients who underwent thyroid surgery from January 1, 2019, to September 31, 2021.
The study sample included 105 adult patients who underwent total thyroidectomy, thyroid lobectomy, or subtotal thyroidectomy in a private health institute, in southwestern, Saudi Arabia.
The field block utilized in all thyroid surgery cases is local wound infiltration of 6–10 ml of 2% lidocaine along the planned incision site.
The type of pain medication prescribed at hospital discharge postoperatively was then retrieved from each patient’s discharge medication list.
Descriptive statistics, frequencies, percentages, arithmetic mean, standard deviation, and 95% confidence intervals (95% CI) for the proportions were computed. The Chi-square test of significance was used to measure the significant differences among variables at a 0.05 significant level. The research followed the declaration of Helsinki’s ethical principles. The research was approved by the research ethics committee of King Khalid University (HAPO-06-B-001; ECM#2021–5913). The need of informed consent was waived by the research ethics committee of King Khalid University as the study was retrospective and observational, involved a completely anonymised data and involved no more than minimal risk to subjects; individual informed consent was not sought.
A total of 105 patients underwent outpatient thyroid surgery during the study period. The majority of patients were females (n = 95, 90.5%) (Fig. 1) and the mean age was 43.3 ± 10.2 years. Among the participants, 52 (49.5%) patients underwent thyroid lobectomy, 44 (41.9%) underwent total thyroidectomies, and 9 (8.6%) underwent subtotal thyroidectomy (Fig. 2).
Oral opioid, by combining paracetamol and codeine, was prescribed to 62 (59%) patients upon discharge (95% CI: 49.5–68.1%), whereas 43 (41%) patients were discharged on paracetamol only (95% CI: 31.5–51.0%) (Fig. 3).
Table 1 shows the distribution of performed surgical procedures by discharge medication. Opioid was prescribed for 63.5% of patients who underwent lobectomy, compared to 54.5% for total thyroidectomy and 55.6% for subtotal thyroidectomy. These differences were not significant (Pearson chi-sq.= 0.833, P = 0.659).
| Discharge Medication | Surgical Procedure | Total Number (%) | ||
|---|---|---|---|---|
| Lobectomy Number (%) | Total Thyroidectomy Number (%) | Subtotal Thyroidectomy Number (%) | ||
| Opioid | 33 (63.5) | 24 (54.5) | 5 (55.6) | 62 (59.0) |
| Paracetamol | 19 (36.5) | 20 (45.5) | 4 (44.4) | 43 (41.0) |
| Total | 52 (100) | 44 (100) | 9 (100) | 105 (100) |
| Pearson chi-sq.= 0.833, P = 0.659 (non-Significant) | ||||
Table 2 shows the distribution of patients’ age groups by discharge medication. Opioid was prescribed for 71.4% of patients aged under 40 years compared to 48.2% among those aged over 40 years. The difference was statistically significant (Pearson chi-sq.= 5.842, P = 0.013).
| Discharge Medication | Age Group | Total Number (%) | |
|---|---|---|---|
| Less than 40 years Number (%) | 40 years and more Number (%) | ||
| Opioid | 35 (71.4) | 27 (48.2) | 62 (59.1) |
| Paracetamol | 14 (28.6) | 29 (51.8) | 43 (40.9) |
| Total | 49 (100) | 56 (100) | 105 (100) |
| Pearson chi-sq.= 5.842, P = 0.013 (Significant) | |||
To the author’s knowledge, this is the first study of its kind to be conducted in Saudi Arabia that presents a unique illustration of physicians prescribing patterns of codeine after thyroid surgery. The study results reveal that a majority of patients were discharged with oral opioids, combining paracetamol and codeine, as postoperative pain medication.
Our finding was similar to the reported studies worldwide, wherein hydrocodone-paracetamol is the most prescribed postoperative opioid medication among American otolaryngologists, followed by oxycodone-paracetamol (18). Codeine-paracetamol is the most prescribed among head and neck surgeons in Canada (19).
Codeine is one of the most widely prescribed opioids in Saudi Arabia, and currently, four codeine-containing products are approved by the Saudi Food and Drug Authority (20) (Table 3). Unfortunately, codeine can be purchased over-the-counter (OTC) from licensed pharmacies without a medical prescription (21, 22). Codeine is a “mild opioid,” but its long-term use can lead to serious medical problems, such as tolerance and addiction (23, 24). This is of paramount importance in areas where patients have unrestricted access to this kind of pain medication, as in our area.
| # | Product | Ingredients |
|---|---|---|
| 1 | Fevadol Plus Tab | Paracetamol (500 mg) + Caffeine (30 mg) + Codeine Phosphate (8 mg) |
| 2 | Solpadine Cap | |
| 3 | Solpadine Soluble Tab | |
| 4 | Actifed Compound Linctus | Each ml contains Triprolidine (30 mg) + Pseudophedrine (10 mg) + Codeine (1.25 mg) |
Among specialties, surgery is the second highest specialty in the rate of opioid prescription after the specialty of pain medicine (25). However, the actual need for opioids was questioned; whereas, a large prospective initiative investigated the postoperative opioid use by patients who underwent 25 different elective procedures and revealed a large proportion of patients who used little or no opioids postoperatively (26). Additionally, a recent meta-analysis that synthesized data from 44 studies to quantify the opioids leftover levels postoperatively revealed that studies of surgery on non-visceral organs (i.e., mastectomy and thyroidectomy) reported significantly more leftover opioids than abdominal or pelvic surgery (27).
However, recently published finding indicates an improvement in the acceptance of surgeons for the use of non-opioid and alternative analgesic strategies in outpatient thyroid and parathyroid surgery as a response to emerging reports on adverse outcomes from excessive pain management (14, 28).
This shift toward non-opioid analgesics was further supported by the Endocrine Surgery Section of the American Head and Neck Society (AHNS-ES), whereas a consensus statement on perioperative pain management and opioid reduction in head and neck endocrine surgery was recently released from AHNS-ES (17). They indicate that “non-opioid medications and adjunctive strategies can effectively manage pain after head and neck or endocrine procedures and reduce postoperative opioid requirements.” Moreover, they stated that “head and neck endocrine surgeons should judiciously utilize opioid medications and only in cases where first-line non-opioid medications are insufficient or medically contraindicated.”
The findings of this study showed that surgeons, in our area of the world, are required to pay more intention to their excessive use of codeine although we acknowledge that the current study has limitations related to its design and relatively low number of subjects. Moreover, setting regulations is necessary to restrict individual access to OTC codeine and limit codeine to prescription-only as adopted in many countries worldwide (29).
Finally, as our study retrospectively focuses solely on postoperative pain management practices in a single institution, we anticipate that future multicentric research will aim to explore further in terms of surgeons’ and patients’ perspectives on efficient postoperative pain management.
This study revealed that some head and neck endocrine surgeons continuously prescribe certain opioids despite emerging evidence that supports the use of non-opioid and alternative analgesic strategies in outpatient thyroid and parathyroid surgery. Further research and quality improvement interventions should be geared toward leading all health professionals to appropriate prescribing practices to improve patient safety and reduce unnecessary opioid prescriptions.
95% CI: 95% confidence intervals
AHNS-ES: Endocrine Surgery Section of the American Head and Neck Society
NSAIDs: non-steroidal anti-inflammatory drugs
OTC: over-the-counter
Ethics approval and consent to participate
The research was was performed in accordance with the Helsinki Declaration of 1964 and subsequent amendments and approved by the research ethics committee of King Khalid University (HAPO-06-B-001; ECM#2021-5913). The need of informed consent was waived by the research ethics committee of King Khalid University as the study was retrospective and observational, involved a completely anonymised data and involved no more than minimal risk to subjects; individual informed consent was not sought.
Consent for publication
Not applicable.
Availability of data and materials
The datasets analyzed during the current study are available from the corresponding author upon reasonable request.
Competing interests
The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence this work. The author declares that he has no conflict of interest.
Funding
No funding and/or sponsorship was received in relation to this paper.
Authors’ contributions
Hassan Alzahrani, the author, performed the study conception and design, material preparation, data collection and part of analysis.
Acknowledgments
I would like to thank Prof. Ahmed Mahfouz for editing the manuscript and Mr. Muhammad Abid Khan for his efforts in the data analysis.
Authors’ information (optional)
Hassan A. Alzahrani, MD, MHPE, MRCS, FRCS, FACS
Email address: [email protected]
Department of Surgery, College of Medicine, King Khalid University
Abha 61421, Saudi Arabia