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      Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients

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          Abstract

          Simple Summary

          Chronic opioid use is a serious global health problem and surgery is often the point of initial exposure for many chronic opioid users. Multimodal analgesia (MMA) is an approach designed to reduce or eliminate opioid use in surgical patients, but it has not been studied in patients having major head and neck surgery. This study explores the impact of an MMA protocol on opioid prescribing practices in patients having major head and neck surgery with flap reconstruction. The results of this study will provide evidence to inform and guide pain management practice in this important patient population. The results of this study could also be applied to other areas of otorhinolaryngology. MMA is an important tool in the effort to reduce chronic opioid use.

          Abstract

          Postoperative opioid use has been linked to the subsequent development of opioid dependency. Multimodal analgesia (MMA) can reduce the use of opioids in the postoperative period, but MMA has not been well-studied after major head and neck surgery. Our goal is to explore the association between MMA and postoperative opioid use and pain control in patients undergoing major head and neck surgery. We performed a retrospective study in adult (age ≥ 18 years) patients undergoing primary head and neck cancer resection with free-flap reconstruction. All patients were treated using an established care pathway. The baseline group was treated between January 2015–December 2015 ( n = 41), prior to the implementation of MMA, and were compared to an MMA-treated cohort treated between December 2017–June 2019 ( n = 97). The primary outcome was the proportion of opioids prescribed and oral morphine equivalents (OMEs) consumed during the hospitalization. The secondary outcome was pain control. We found that the post-MMA group consumed fewer opioids in the postoperative period compared to the pre-MMA group. Prior to post-operative day (POD) 6, pain control was better in the post-MMA group; however, the pain control lines intersect on POD 6 and the pre-MMA group appeared to have better pain control from PODs 7–10. In conclusion, our data suggest MMA is an effective method of pain control and opioid reduction in patients undergoing surgery for head and neck cancer with free flap reconstruction. MMA use was associated with a significant decrease in the quantity of opioids consumed postoperatively. The MMA protocol was associated with improved pain management early in the postoperative course. Finally, the MMA protocol is a feasible method of pain control and may reduce the adverse side effects associated with opioid use.

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          Most cited references32

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          Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review.

          Amid the current opioid epidemic in the United States, the enhanced recovery after surgery pathway (ERAS) has emerged as one of the best strategies to improve the value and quality of surgical care and has been increasingly adopted for a broad range of complex surgical procedures. The goal of this article was to outline important components of opioid-sparing analgesic regimens.
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            Characteristics of opioid prescriptions in 2009.

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              Prevalence of pain in patients with cancer: a systematic review of the past 40 years.

              Despite the abundant literature on this topic, accurate prevalence estimates of pain in cancer patients are not available. We investigated the prevalence of pain in cancer patients according to the different disease stages and types of cancer. A systematic review of the literature was conducted. An instrument especially designed for judging prevalence studies on their methodological quality was used. Methodologically acceptable articles were used in the meta-analyses. Fifty-two studies were used in the meta-analysis. Pooled prevalence rates of pain were calculated for four subgroups: (i) studies including patients after curative treatment, 33% [95% confidence interval (CI) 21% to 46%]; (ii) studies including patients under anticancer treatment: 59% (CI 44% to 73%); (iii) studies including patients characterised as advanced/metastatic/terminal disease, 64% (CI 58% to 69%) and (iii) studies including patients at all disease stages, 53% (CI 43% to 63%). Of the patients with pain more than one-third graded their pain as moderate or severe. Pooled prevalence of pain was >50% in all cancer types with the highest prevalence in head/neck cancer patients (70%; 95% CI 51% to 88%). Despite the clear World Health Organisation recommendations, cancer pain still is a major problem.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                Cancers (Basel)
                Cancers (Basel)
                cancers
                Cancers
                MDPI
                2072-6694
                12 March 2021
                March 2021
                : 13
                : 6
                : 1266
                Affiliations
                [1 ]Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; avhinthe@ 123456ucalgary.ca (A.H.); shamir.chandarana@ 123456ucalgary.ca (S.P.C.); wmatthew@ 123456ucalgary.ca (T.W.M.); Robert.Hart@ 123456albertahealthservices.ca (R.H.)
                [2 ]Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; scnakone@ 123456ucalgary.ca
                [3 ]Section of Plastic and Reconstructive Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; cschrag@ 123456me.com (C.S.); jennifer.matthews1@ 123456me.com (J.M.); cdavidmckenzie@ 123456mac.com (C.D.M.)
                [4 ]Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; ghfick@ 123456ucalgary.ca
                Author notes
                [* ]Correspondence: jdort@ 123456ucalgary.ca ; Tel.: +1-403-220-7268
                [†]

                These authors contributed equally to this paper.

                Author information
                https://orcid.org/0000-0002-8920-0310
                https://orcid.org/0000-0001-6612-4717
                https://orcid.org/0000-0002-0858-187X
                Article
                cancers-13-01266
                10.3390/cancers13061266
                7999688
                33809273
                48efb221-9e12-40d1-8534-f45d0108343e
                © 2021 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 20 January 2021
                : 10 March 2021
                Categories
                Article

                multimodal analgesia,perioperative pain control,postoperative pain,head and neck surgery,head and neck cancer

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