Response to Confounding Factors on the Prediction of Opioid Usage after Thyroidectomy and Parathyroidectomy Surgery

Abstract

We read with interest Dr Kang’s comments on our recent publication.¹ We would like to provide our response to the 3 important points outlined by the author.

First, we did not report data on the use of intraoperative opioids. We currently do not have a standardized protocol for intraoperative opioid use for thyroidectomy and parathyroidectomy surgery at our institution and did not collect data quantifying anesthesiologist-administered analgesia.

Second, we did not quantify the type and amount of postoperative nonopioid analgesics in our statistical model. The types of nonopioid analgesics reported to be taken included varying doses and combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentin, benzocaine-menthol, and capsaicin cream. Many patients took nonopioid analgesics without a prescription, leading to difficulty ascertaining the amount taken. We found that there was too much variation in type and amount of nonopioid analgesia used to include precise quantities of nonopioids as a variable in our analysis. We agree that the author’s points 1 and 2 are limitations of our study. A systematic approach to intraoperative analgesia and postoperative nonopioid analgesics for endocrine surgery as part of an Enhanced Recovery After Surgery (ERAS) protocol would help to standardize postoperative pain control, allow for more precise analysis of analgesic use, and potentially decrease postoperative opioid use. Our department has adopted a policy of recommending alternating ibuprofen and acetaminophen after endocrine surgery, and since implementing this change, we have anecdotally had excellent results (ie, no patient complaints or phone calls for refills).

Third, we attempted to limit the number of independent variables in our logistic regression models to minimize model overfitting. The model in question, patients taking at least 10 opioid pills (Table 3), had 15 of 87 events and 3 independent variables, which included age (continuous), sex (binary), and Charlson comorbidity index quartile (4-level categorical). The logistic regression model of patients taking opioids at all had 51 of 87 events and 4 independent variables, including age, sex, body mass index (continuous), and Charlson quartile (Table 2).

We would like to thank the author for constructive comments and for helping us identify potential areas of future investigation.

Disclosures

Competing interests: Richard V. Smith, AAO-HNS (education coordinator stipend), UptoDate (author royalty), Plural Publishing (author royalty), and Elsevier (author royalty).

Sponsorships: None.

Funding source: NIH-NIDCR K23 grant 1 K23 DE027425-01. Thomas J. Ow’s contribution was supported by NIH-NIDCR K23 grant 1 K23 DE027425-01. The manuscript content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Theresa Tharakan Albert Einstein College of Medicine, Bronx, New York, USA Sydney Jiang, MD Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA Judd Fastenberg, MD Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA Thomas J. Ow, MD, MS Albert Einstein College of Medicine, Bronx, New York, USA Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA Department of Pathology, Montefiore Medical Center, Bronx, New York, USA Bradley Schiff, MD Richard V. Smith, MD Vikas Mehta, MD, MPH Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA

Footnotes

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

References

Tharakan

Jiang

Fastenberg

et al. Postoperative pain control and opioid usage patterns among patients undergoing thyroidectomy and parathyroidectomy. Otolaryngol Head Neck Surg. 2019;160:394-401.