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Patient-Centered Decision-making for Postoperative Narcotic-Free Endocrine SurgeryA Randomized Clinical Trial

Educational objective To determine the effect of an opt-in program of patient-centered decision-making for narcotic-free endocrine surgery on the use of narcotics postoperatively.
1 Credit CME
Key Points

Question  Does limiting opioid prescription to patients who request it (ie, opt-in program) decrease the quantity of opioids prescribed and consumed compared with patients given a routine prescription after outpatient cervical endocrine surgery?

Findings  In this randomized clinical trial of 102 adults undergoing thyroidectomy or parathyroidectomy, patients randomized to the opt-in program were prescribed less opioids without reporting worse postoperative pain scores or health-related quality of life. No patients who opted out required a rescue opioid prescription.

Meaning  In this randomized clinical trial, an opt-in strategy for opioid prescriptions after endocrine surgery was noninferior to use of routine prescriptions with respect to postoperative pain and reduced overprescription of opioids.


Importance  Historically, opioid pain medications have been overprescribed following thyroid and parathyroid surgery. Many narcotic prescriptions are incompletely consumed, creating waste and opportunities for abuse.

Objective  To determine whether limiting opioid prescriptions after outpatient thyroid and parathyroid surgery to patients who opt in to narcotic treatment reduces opioid consumption without increasing postoperative pain compared with usual care (routine narcotic prescriptions).

Design, Setting, and Participants  A randomized clinical trial of Postoperative Opt-In Narcotic Treatment (POINT) or routine narcotic prescription (control) was conducted at a single tertiary referral center from June 1 to December 30, 2020. A total of 180 adults undergoing ambulatory cervical endocrine surgery, excluding patients currently receiving opioids, were assessed for eligibility. POINT patients received perioperative pain management counseling and were prescribed opioids only on patient request. Patients reported pain scores (0-10) and medication use through 7 daily postoperative surveys. Logistic regression was used to determine factors associated with opioid consumption.

Interventions  Patients in the POINT group were able to opt in or out of receiving prescriptions for opioid pain medication on discharge. Control patients received routine opioid prescriptions on discharge.

Main Outcomes and Measures  Daily peak pain score through postoperative day 7 was the primary outcome. Noninferiority was defined as a difference less than 2 on an 11-point numeric rating scale from 0 to 10. Analysis was conducted on the evaluable population.

Results  Of the 180 patients assessed for eligibility, the final study cohort comprised 102 patients: 48 randomized to POINT and 54 to control. Of these, 79 patients (77.5%) were women and median age was 52 (interquartile range, 43-62) years. A total of 550 opioid tablets were prescribed to the control group, and 230 tablets were prescribed to the POINT group, in which 23 patients (47.9%) opted in for an opioid prescription. None who opted out subsequently required rescue opioids. In the first postoperative week, 17 POINT patients (35.4% of survey responders in the POINT group) reported consuming opioids compared with 27 (50.0%) control patients (P = .16). Median peak outpatient pain scores were 6 (interquartile range, 4-8) in the control group vs 6 (interquartile range, 5-7) in the POINT group (P = .71). In multivariate analysis, patients with a history of narcotic use were 7.5 times more likely to opt in (95% CI, 1.61-50.11; P = .02) and 4.8 times more likely to consume opioids (95% CI, 1.04-1.52; P = .01). Higher body mass index (odds ratio, 1.11; 95% CI, 1.01-1.23; P = .03) and highest inpatient postoperative pain score (odds ratio, 1.24; 95% CI, 1.04-1.52; P = .02) were also associated with opioid consumption.

Conclusions and Relevance  In this trial, an opt-in strategy for postoperative narcotics reduced opioid prescription without increasing pain after cervical endocrine surgery.

Trial Registration  ClinicalTrials.gov Identifier: NCT04710069

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Article Information

Accepted for Publication: June 28, 2021.

Published Online: September 8, 2021. doi:10.1001/jamasurg.2021.4287

Correction: This article was corrected on November 10, 2021, to fix a funding/support omission in the end matter.

Corresponding Author: Catherine Y. Zhu, MD, Department of General Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 72-228 CHS, Los Angeles, CA 90095 (catherinezhu@mednet.ucla.edu).

Author Contributions: Drs Zhu and Wu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zhu, Schumm, Lin, Yeh, Wu.

Acquisition, analysis, or interpretation of data: Zhu, Schumm, Hu, Nguyen, Kim, Tseng, Yeh, Livhits, Wu.

Drafting of the manuscript: Zhu, Schumm, Hu, Nguyen, Wu.

Critical revision of the manuscript for important intellectual content: Zhu, Schumm, Hu, Kim, Tseng, Lin, Yeh, Livhits, Wu.

Statistical analysis: Zhu, Nguyen, Kim, Tseng, Wu.

Obtained funding: Yeh.

Administrative, technical, or material support: Zhu, Schumm, Nguyen, Lin, Yeh, Wu.

Supervision: Zhu, Yeh, Livhits, Wu.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Schumm is supported by a grant from the H&H Lee Research Program.

Role of the Funder/Sponsor: The H&H Lee Research Program had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Wetzel  M , Hockenberry  J , Raval  MV .  Interventions for postsurgical opioid prescribing: a systematic review.   JAMA Surg. 2018;153(10):948-954. doi:10.1001/jamasurg.2018.2730 PubMedGoogle ScholarCrossref
American College of Surgeons. Statement on the opioid abuse epidemic. August 2, 2017. Accessed February 18, 2021. https://www.facs.org/About-ACS/Statements/100-opioid-abuse
Habermann  EB .  Are opioids overprescribed following elective surgery?   Adv Surg. 2018;52(1):247-256. doi:10.1016/j.yasu.2018.03.003 PubMedGoogle ScholarCrossref
Lancaster  E , Inglis-Arkell  C , Hirose  K ,  et al.  Variability in opioid-prescribing patterns in endocrine surgery and discordance with patient use.   JAMA Surg. 2019;154(11):1069-1070. doi:10.1001/jamasurg.2019.2518 PubMedGoogle ScholarCrossref
Shindo  M , Lim  J , Leon  E , Moneta  L , Li  R , Quintanilla-Dieck  L .  Opioid prescribing practice and needs in thyroid and parathyroid surgery.   JAMA Otolaryngol Head Neck Surg. 2018;144(12):1098-1103. doi:10.1001/jamaoto.2018.2427 PubMedGoogle ScholarCrossref
Lou  I , Chennell  TB , Schaefer  SC ,  et al.  Optimizing outpatient pain management after thyroid and parathyroid surgery: a two-institution experience.   Ann Surg Oncol. 2017;24(7):1951-1957. doi:10.1245/s10434-017-5781-y PubMedGoogle ScholarCrossref
McCrary  HC , Newberry  CI , Casazza  GC , Cannon  RB , Ramirez  AL , Meier  JD .  Evaluation of opioid prescription patterns among patients undergoing thyroid surgery.   Head Neck. 2021;43(3):903-908. doi:10.1002/hed.26551PubMedGoogle ScholarCrossref
Lipari  HA .  How People Obtain the Prescription Pain Relievers They Misuse: The CBHSQ Report. Center for Behavioral Health Statistics and Quality, Substances and Metal Health Services Administration; 2013.
Alam  A , Gomes  T , Zheng  H , Mamdani  MM , Juurlink  DN , Bell  CM .  Long-term analgesic use after low-risk surgery: a retrospective cohort study.   Arch Intern Med. 2012;172(5):425-430. doi:10.1001/archinternmed.2011.1827 PubMedGoogle ScholarCrossref
Marcusa  DP , Mann  RA , Cron  DC ,  et al.  Prescription opioid use among opioid-naive women undergoing immediate breast reconstruction.   Plast Reconstr Surg. 2017;140(6):1081-1090. doi:10.1097/PRS.0000000000003832 PubMedGoogle ScholarCrossref
Brummett  CM , Waljee  JF , Goesling  J ,  et al.  New persistent opioid use after minor and major surgical procedures in US adults.   JAMA Surg. 2017;152(6):e170504-e170504. doi:10.1001/jamasurg.2017.0504 PubMedGoogle ScholarCrossref
Sun  EC , Darnall  BD , Baker  LC , Mackey  S .  Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period.   JAMA Intern Med. 2016;176(9):1286-1293. doi:10.1001/jamainternmed.2016.3298 PubMedGoogle ScholarCrossref
Olds  C , Spataro  E , Li  K , Kandathil  C , Most  SP .  Assessment of persistent and prolonged postoperative opioid use among patients undergoing plastic and reconstructive surgery.   JAMA Facial Plast Surg. 2019;21(4):286-291. doi:10.1001/jamafacial.2018.2035 PubMedGoogle ScholarCrossref
Ruffolo  LI , Jackson  KM , Juviler  P ,  et al.  Narcotic free cervical endocrine surgery: a shift in paradigm.   Ann Surg. 2021;274(2):e143-e149. PubMedGoogle Scholar
Arroll  B , Goodyear-Smith  F , Crengle  S ,  et al.  Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population.   Ann Fam Med. 2010;8(4):348-353. doi:10.1370/afm.1139 PubMedGoogle ScholarCrossref
Larach  DB , Sahara  MJ , As-Sanie  S ,  et al.  Patient factors associated with opioid consumption in the month following major surgery.   Ann Surg. 2021;273(3):507-515. doi:10.1097/SLA.0000000000003509 PubMedGoogle ScholarCrossref
Ip  HY , Abrishami  A , Peng  PW , Wong  J , Chung  F .  Predictors of postoperative pain and analgesic consumption: a qualitative systematic review.   Anesthesiology. 2009;111(3):657-677. doi:10.1097/ALN.0b013e3181aae87a PubMedGoogle ScholarCrossref
Cella  D , Riley  W , Stone  A ,  et al; PROMIS Cooperative Group.  The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008.   J Clin Epidemiol. 2010;63(11):1179-1194. doi:10.1016/j.jclinepi.2010.04.011 PubMedGoogle ScholarCrossref
VanderWeele  TJ , McNeely  E , Koh  HK .  Reimagining health-flourishing.   JAMA. 2019;321(17):1667-1668. doi:10.1001/jama.2019.3035 PubMedGoogle ScholarCrossref
Diener  E , Wirtz  D , Tov  W ,  et al.  New well-being measures: short scales to assess flourishing and positive and negative feelings.   Social Indicators Research. 2010;97(2):143-156. doi:10.1007/s11205-009-9493-y Google ScholarCrossref
Kahneman  D.   Thinking, Fast and Slow. Farrar, Straus and Giroux; 2011.
Norman  GR , Sloan  JA , Wyrwich  KW .  Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation.   Med Care. 2003;41(5):582-592. doi:10.1097/01.MLR.0000062554.74615.4C PubMedGoogle Scholar
Howard  R , Fry  B , Gunaseelan  V ,  et al.  Association of opioid prescribing with opioid consumption after surgery in Michigan.   JAMA Surg. 2019;154(1):e184234-e184234. doi:10.1001/jamasurg.2018.4234 PubMedGoogle ScholarCrossref
Harbaugh  CM , Lee  JS , Chua  K-P ,  et al.  Association between long-term opioid use in family members and persistent opioid use after surgery among adolescents and young adults.   JAMA Surg. 2019;154(4):e185838-e185838. doi:10.1001/jamasurg.2018.5838 PubMedGoogle ScholarCrossref
Chen  Y , Nwaogu  I , Chomsky-Higgins  K ,  et al.  Postoperative pain and opioid use after thyroid and parathyroid surgery—a pilot, prospective SMS-based survey.   J Surg Res. 2019;240:236-240. doi:10.1016/j.jss.2019.03.016 PubMedGoogle ScholarCrossref
Cai  H-D , Lin  C-Z , Yu  C-X , Lin  X-Z .  Bilateral superficial cervical plexus block reduces postoperative nausea and vomiting and early postoperative pain after thyroidectomy.   J Int Med Res. 2012;40(4):1390-1398. doi:10.1177/147323001204000417 PubMedGoogle ScholarCrossref
Karthikeyan  VS , Sistla  SC , Badhe  AS ,  et al.  Randomized controlled trial on the efficacy of bilateral superficial cervical plexus block in thyroidectomy.   Pain Pract. 2013;13(7):539-546. doi:10.1111/papr.12022 PubMedGoogle ScholarCrossref
Kwan  SY , Lancaster  E , Dixit  A ,  et al.  Reducing opioid use in endocrine surgery through patient education and provider prescribing patterns.   J Surg Res. 2020;256:303-310. doi:10.1016/j.jss.2020.06.025 PubMedGoogle ScholarCrossref
Oyler  DR , Randle  RW , Lee  CY , Jenkins  G , Chang  PK , Sloan  DA .  Implementation of opioid-free thyroid and parathyroid procedures: a single center experience.   J Surg Res. 2020;252:169-173. doi:10.1016/j.jss.2020.03.010 PubMedGoogle ScholarCrossref
Rhon  DI , Snodgrass  SJ , Cleland  JA , Sissel  CD , Cook  CE .  Predictors of chronic prescription opioid use after orthopedic surgery: derivation of a clinical prediction rule.   Perioper Med (Lond). 2018;7(1):25. doi:10.1186/s13741-018-0105-8 PubMedGoogle ScholarCrossref
O’Connell  C , Azad  TD , Mittal  V ,  et al.  Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes.   Neurosurg Focus. 2018;44(1):E5. doi:10.3171/2017.10.FOCUS17563 PubMedGoogle Scholar
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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