Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Patient-controlled analgesia (PCA) with opioids presents serious risks for patients postoperatively, including dependence, excessive sedation, and respiratory depression. When used as a standard for postoperative pain management, PCA may also exacerbate unnecessary opioid overuse. We sought to determine if a multimodal pain control regimen would be similarly effective to PCA for pain management in patients who undergo oral cavity resection with free flap reconstruction for treatment of a head and neck malignancy.
Methods: Patients who underwent oral cavity resection with free flap reconstruction for treatment of a head and neck malignancy at our tertiary centre between November 2023 and August 2024 received either PCA (intravenous morphine, hydromorphone, or fentanyl) or a standing regimen of oral acetaminophen and celecoxib (with or without gabapentin) with oral opioids for breakthrough pain. Patients were allocated to groups based on surgeon-anesthesiologist discussions anticipating the need for opioid self-administration. Demographic data including patient age, sex, smoking status, cannabis use, comorbidities, and head and neck cancer history were collected. The primary outcome was morphine milligram equivalent (MME) use which was measured daily for both groups until discharge. Pain was self-reported by patients daily using the validated 11-point Numeric Pain Rating Scale. Independent samples t-tests were used to compare differences in mean MME use and pain between groups. Chi-squared tests were used to assess group differences in demographic characteristics.
Results: A total of 145 patients were included in the study; 105 (72%) received PCA and 40 (28%) received multimodal analgesia only. Patients were 41% female (n=59) and 59% male (n=86) with a mean age of 64.6 (SD=12.6) at the time of surgery. Seventy-four patients (51%) had a smoking history and 29 (20%) were current or former cannabis users. Head and neck radiation history was reported in 46 patients (32%). Chronic pain history was reported in 10.3% of patients (n=15), and mean Charlson Comorbidity Index was 5.83 (SD=2.71). There were no significant differences in any demographic characteristics between the two groups. MME use was significantly lower in the non-PCA group at all postoperative timepoints, with the greatest mean differences observed on postoperative day (POD) 1 (MD=-116, SD=13.1, 95% CI: -142 to -89.9, p<0.001) and POD 2 (MD=-54.2, SD=8.4, 95% CI: -70.8 to -37.5, p<0.001). There were no statistically significant differences in patients’ pain ratings between groups on POD 1 or PODs 3 to 5. Statistically significant lower pain scores were reported in the non-PCA group on POD 2 (MD=-1.42, SD=0.522, 95% CI: -2.45 to -0.39, p=0.007) and PODs 6 to discharge (MD=-0.94, SD=0.45, 95% CI: -1.84 to -0.05, p=0.039).
Conclusions: A multimodal pain control regimen which uses acetaminophen, celecoxib, gabapentin, and oral opioids can be equally or more effective for managing pain in patients who undergo oral cavity resection for head and neck malignancy versus PCA with intravenous opioids. Our non-PCA regimen resulted in a significantly smaller opioid dosage for patients and can help reduce the risks of serious complications associated with postoperative opioid use in this population.