Surgery often comes with pain during the healing process, and recovery from soft palate surgery for obstructive sleep apnea, in particular, is painful. There is wide variation in approaches taken to pain management after soft palate surgery, and I was fortunate to be involved in a 2019 publication from an international group presenting consensus-based recommendations for pain management. One of the key areas of agreement was “alternative pain management options perioperatively to reduce opioid use should be considered.”

Pain control and pain management are goals after soft palate surgery because uncontrolled or poorly-managed pain can lead a patient to a situation of dehydration or low calorie (especially low protein) intake. This can results in a wide array of issues: feeling terrible, poor healing, readmission to the hospital, or health concerns including death. On the other hand, narcotic pain medications have their own risks, including decreasing the  drive to breathe or reducing the ability of someone to wake up if they have blockage of breathing. Fortunately, we are able to balance these by monitoring patients closely as they stay overnight in the hospital for at least the first night after surgery. There, we can make sure they are not getting into trouble as we work together to control their pain while the medications they received during general anesthesia also clear out of their system.

Using science to reduce narcotic needs

As I started my career over 20 years ago, we would give patients intravenous medication to cut down swelling but then provide relatively high doses of narcotics. Although we took all precautions to make sure this was safe during that first night after surgery in the hospital, looking back it seems that we were relatively lucky not to run into problems. Over time, I have adopted a number of approaches that have made a real difference in narcotic use, largely based on the fact that pain after palate surgery is related to the amount of swelling. In order of my starting to use them, the changes have been:

• Ice in the mouth. I just have patients hold 1-2 pieces of ice in their mouth, letting them dissolve slowly. This is similar to applying ice to your ankle after a sprain.
• Tylenol/acetaminophen on a scheduled basis. The textbooks that I used in medical school suggested that acetaminophen did not decrease swelling, but it turns out that 1000 mg of Tylenol every 6 hours has been shown to decrease swelling.
• Celebrex/celecoxib on a scheduled basis. Because NSAIDs like ibuprofen increase the risk of bleeding, I had avoided them. However, celecoxib is a COX-2 inhibitor that uniquely does not seem to do this, at least in the laboratory setting. In 2018, I started using celecoxib routinely.

Spreading the word…and not just on this blog

I have long believed that these changes improved the pain experience of my patients and their narcotic pain medication needs. So we studied our own experience, and the results have just been published in the medical journal Otolaryngology – Head and Neck Surgery. Ido Badash, MD led this study that examined a series of 210 patients in whom I performed soft palate surgery for obstructive sleep apnea during my time at USC. We evaluated the use of acetaminophen and celecoxib and the association with use of narcotics in the hospital for the first 24 hours after surgery. Celecoxib was associated with a decrease in narcotic use in the first 24 hours after surgery, with our typical amounts reducing oxycodone use by about 10 mg, about 30% of the total amount of narcotics. If anything, this understates the impact of celecoxib because I tend to use higher doses in patients who are more muscular and younger, patient groups that tend to need higher doses of narcotics in my experience. Acetaminophen was not associated with narcotic use, although because almost all of these individuals received acetaminophen, it was not possible to evaluate acetaminophen properly.

Is this a big deal? It is to my patients and me!

By itself, reducing oxycodone use by 10 mg is not a major difference. However, a more-meaningful measure of the impact is the reduction in narcotic use by 30% in that first 24 hours. My experience is that this reduction in narcotic use persists over the entire recovery period. I certainly have decreased the amount of narcotics I prescribe to patients during hospital discharge and also have almost no patients asking for narcotic pain medication refills, something that was common prior to my use of celecoxib.

I feel that my use of celecoxib has been one of the most important changes to how I manage patients after surgery, making the recovery easier and safer for patients. For this, I am indebted to Kevin Guthmiller, MD, an outstanding anesthesiologist at USC who encouraged me to consider using it, explaining its special properties that have made it a mainstay of my postoperative care.