International perioperative pain management approaches

Introduction

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. ^,

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.

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.