Factors Influencing Postoperative Opioid Use following Endoscopic Skull Base Surgery

Introduction: Opioid abuse is a public health crisis and, for many patients, the perioperative period is often the time of first opioid exposure. There is a need to identify risk factors for increased postoperative pain, as a way to individualize pain management regimens and reduce opioid prescriptions. The purpose of this study was to further investigate the role of anxiety and depression on opioid use following endoscopic skull base surgery (ESBS).

Methods: Longitudinal, prospective cohort study of adult patients scheduled to undergo (ESBS) between November 2019 and March 2020 at a single institution. Combined open and endoscopic procedures were excluded. Preoperatively, patients completed questionnaires regarding medical history, sinonasal outcome test (SNOT-22), generalized anxiety disorder 2-item (GAD-2), and patient health questionnaire-2 (PHQ-2). At discharge, patients were encouraged to use non-opioid pain medication as first-line therapy and received a prescription for 10 to 12 oxycodone tablets. Patients were contacted via telephone every 48 hours following surgery and asked to quantify facial pain and opioid consumption, until no longer requiring opioids. Patients were contacted again at two months postoperatively to inquire about opioid disposal.

Results: Thirty-three patients were included with an average age of 47 years. The female:male ratio was 2:1. 28 patients underwent ESBS for sellar lesions (adenoma, cyst) with the remaining 5 patients comprised of meningioma, esthesioneuroblastoma, anterior cranial fossa inverted papilloma, fibrous dysplasia, and anterior cranial fossa encephalocele with CSF leak. Average length of hospital stay was 4 days. The average total milligrams morphine equivalents (MME) utilized postoperatively was 381.9 (range: 0–1,665). A documented history of headache disorder was significantly associated with higher total MME (p = 0.025). History of depression approached being significantly associated with higher total MME (p = 0.053). Among patients with depression, there was no difference in total MME among those treated with antidepressants compared with those without. Higher total MME was not associated with nasoseptal flap (NSF) usage, anxiety, pain expectation, smoking history, marijuana, illicit drug use, preoperative head pain, or length of stay. There was no significant difference in total MME utilized between sellar and non-sellar lesions. There was no significant difference in MME used per patient between the inpatient and outpatient settings. 94% of patients were using opioids on postoperative day 2 (94% still inpatient), 58% on day 6 (12% still inpatient), and 27% by day 10 (3% still inpatient). Of patients still requiring opioids on postoperative day 10, 67% had a nasoseptal flap and 44% had undergone revision surgery. Headache disorder (p = 0.01), depression (p = 0.03), and anxiety (p = 0.03) were all associated with longer duration of opioid use.

Conclusion: After ESBS, patients utilized an average of 381.9 MME and 70% required them for 10 days or less. Greater total MME was significantly associated with documented history of headaches and approached a significant association with history of depression. Use of antidepressants did not appear to impact total MME. Overall, opioid use declined among all patients in the postoperative period, but longer duration of use was associated with headaches, depression, and anxiety.

Publikationsverlauf

Artikel online veröffentlicht:
12. Februar 2021