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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

JAMA Surgery

Published Online: September 8, 2021

Original Investigation

Article Information and Disclosures

Catherine Y. Zhu, MD¹;

Max A. Schumm, MD¹;

Theodore X. Hu, MPhil¹;

Dalena T. Nguyen, MPH¹;

Jiyoon Kim, MS²;

Chi-Hong Tseng, PhD³;

Anne Y. Lin, MD¹;

Michael W. Yeh, MD¹;

Masha J. Livhits, MD¹;

James X. Wu, MD¹

Author Affiliations

¹Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
²Department of Biostatistics, UCLA School of Public Health, Los Angeles, California
³Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California

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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.

Abstract

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.

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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.