Assessment of Opioid Use and Analgesic Requirements After Endoscopic Sinus Surgery

Abstract

IMPORTANCEThe opioid epidemic has generated interest in optimizing opioid prescribing after common surgeries. Recent studies have shown a broad range of analgesic prescription patterns following endoscopic sinus surgery (ESS).OBJECTIVE To compare the efficacy of different analgesic regimens after ESS. DESIGN, SETTING, AND PARTICIPANTSThis multi-institutional, nonblinded randomized clinical trial was conducted at 6 tertiary centers across the US and Canada and included participants who underwent ESS for acute or chronic rhinosinusitis. The study was conducted from March 2019 to March 2020, and the data were analyzed in November to December 2020.INTERVENTIONS All participants received acetaminophen, 650 mg, as the first-line analgesic. From there, patients were randomized to either oxycodone rescue (oxycodone, 5 mg, as second-line therapy) or ibuprofen rescue (ibuprofen, 600 mg, as second-line therapy, with oxycodone, 5 mg, reserved for breakthrough pain).MAIN OUTCOMES AND MEASURES Baseline characteristics and disease severity were collected at enrollment. Medication logs, pain scores, and epistaxis measures were collected until postoperative day 7. The primary outcome was the postoperative visual analog scale score for pain. Brief Pain Inventory Pain Severity and Pain Interference Scores were also collected. RESULTS A total of 118 patients were randomized (62 [52.5%] oxycodone rescue, 56 [47.5%] ibuprofen rescue; mean [SD] age, 46.7 [16.3] years; 44 women [44.0%]; 83 White [83.0%], 7 Black [7.0%], and 7 Asian individuals [7.0%]). After exclusions for loss to follow-up and noncompliance, 51 remained in the oxycodone rescue group and 49 in the ibuprofen rescue group. The groups had similar demographic characteristics and disease severity. Thirty-two (63%) in the oxycodone rescue group had adequate pain management with acetaminophen only, while 19 (37%) consumed at least 1 oxycodone dose. In the ibuprofen rescue group, 18 (16%) required only acetaminophen, 28 (57%) used only acetaminophen and ibuprofen, and the remaining 13 (26%) consumed 1 or more oxycodone doses. The groups had similar average acetaminophen (9.69 vs 7.96 doses; difference, 1.73; 95% CI, -1.37 to 4.83) and oxycodone (1.89 vs 0.77 doses; difference, 1.13; 95% CI, -0.11 to 2.36) use. Both groups had similar postoperative visual analog scale scores. A subanalysis that compared opioids users with nonusers showed clinically significant lower pain scores in nonusers at multiple postoperative points. CONCLUSIONS AND RELEVANCEIn this randomized clinical trial, most patients who underwent ESS could be treated postoperatively using a nonopioid regimen of either acetaminophen alone or acetaminophen and ibuprofen. Ibuprofen as a second-line therapy did not reduce overall narcotic consumption, but the overall narcotic use was low in both groups.TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03783702

Peri-Operative Pain and Opioid Use in Opioid-Naïve Patients Following Inpatient Head and Neck Surgery

“…Despite the aforementioned progress, opioid medications continue to be prescribed in excess of patients' needs following tonsillectomy (21) and other common Otolaryngology surgeries (2,3), with similar findings in other surgical fields (1,17,36). Our data is limited without information about opioid consumption following discharge from the hospital.…”

“…Multiple studies across surgical specialties have shown that patients are prescribed opioids in excess of their postoperative requirements (1,2). With excess medication available, patients are more likely to use opioids for prolonged periods of time, thereby increasing the risk for chronic opioid use (3). Additionally, unused medication has the potential for diversion (1).…”

“…Recent efforts have been made across the United States to limit inappropriate prescribing of opioids, and clinical practice guidelines have been developed to improve management of pain in the perioperative setting (16)(17)(18). Within the Otolaryngology literature, studies have focused on evaluating various multimodal analgesic regimens for post-operative pain management following tonsillectomy (19), as it's one of the most painful surgical procedures (20,21), and endoscopic sinus surgery (3,22), given the high volume of cases. However, there are limited data on peri-operative pain management for complex HNC patients following inpatient procedures.…”

Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery

“…25 There are also increasing data that NSAIDs, which were not investigated in this study, prescribed postoperatively as part of a multimodal regimen can be effective at managing pain and decreasing opioid consumption in otolaryngologic surgery without increasing bleeding risk. 20,24,26…”

“…A recent randomized multicenter study of endoscopic sinus surgery demonstrated that the mean consumption of opioid tablets was <2 and that the majority of patients were able to control pain adequately with a regimen of acetaminophen and ibuprofen. 26 In rhinoplasty surgery, an average of 6 or 7 opioid pills are consumed postoperatively when prescribed with acetaminophen and ibuprofen. 17 Further study is certainly needed to determine the appropriate level of opioids to prescribe that reduces excess but is still able to sufficiently control postoperative pain.…”