Postoperative opioid‐prescribing practices in otolaryngology: A multiphasic study

Abstract

Objectives In otolaryngology, postoperative pain management lacks evidence‐based guidelines. We designed a prospective, multiphasic study aimed to develop evidence‐based guidelines for postoperative pain management within our institution. In this first phase of our project, we investigated opioid prescription and consumption as well as pain trends for common otolaryngologic procedures. Methods Patients (n = 161) who underwent procedures between July 2018 and February 2019 were surveyed on their postoperative opioid usage and pain from day of discharge to first clinic visit. Opioid prescriptions were converted to standardized units of morphine milligram equivalents (MME). The procedures selected for analysis were parathyroidectomy/thyroidectomy, parotidectomy, sialendoscopy, and transoral robotic surgery resection (TORS). Results In total, 19,748 MME were prescribed: 8,588 MME (43.5%) were used, leaving 11,159 MME (56.5%) unused. TORS average MME used: 221 ± 227; total MME unused: 38%. Sialendoscopy average MME used: 31 ± 46; total MME unused: 67%. Parathyroidectomy/thyroidectomy average MME used: 30 ± 37; total MME unused: 66%. Parotidectomy average MME used: 43 ± 53; total MME unused: 65%. Male gender, smoking (current and former), and psychiatric medication use were positive predictors of opioid consumption in postoperative patients (P < 0.001). Conclusion At our institution, over 50% of prescribed postoperative opioids went unused. This was most pronounced for nonmucosal surgeries. Postoperative pain management should account for this to minimize unnecessary opioid prescriptions. Based on our findings and review of current literature, we are in the process of developing prescribing recommendations to be implemented within our institution. Level of Evidence 2 Laryngoscope, 130:659–665, 2020

Postoperative Opioid Use and Pain Management Following Otologic and Neurotologic Surgery

“…They found that of the 19 748 morphine milligram equivalents prescribed, 56.5% went unused. 7 Our data suggest similar overestimation of postoperative pain needs following otologic surgeries, with patients using a median of four pills, or only 27%, of the median number of pills prescribed at discharge. A moderate correlation was noted between reported pain scores and number of opioids used postoperatively, suggestive of an appropriate increase in medication use in response to increasing pain levels.…”

“…Several studies have demonstrated the inefficiency of surgeons to estimate postoperative opioid needs, with patients often using <50% of their prescribed quantity of opioids. 5-7 Pressure to adequately treat each patient’s pain, coupled with limitations in the ability to electronically prescribe opioids if patients run out of medication, likely lead to overprescribing in the immediate postoperative period. The vast range of surgical procedures performed today, along with a recognition of variable pain tolerance levels among individuals, make development of standardized prescription recommendations difficult.…”

Postoperative Analgesia Protocol: A Resident‐Led Effort to Standardize Opioid Prescribing Patterns

“…Studies show that opioids make up 37% of all prescription medications written by surgeons, surpassed only by pain management specialists at 49% 3,4 . However, in contrast to many chronic pain patients, postsurgical patients report not using over half of the opioid pills prescribed to them 5‐7 …”

“…In a 2015 review of Medicare beneficiaries, otolaryngologists were found to have prescribed nearly 1 million days of opioids within this population alone, which represented less than 20% of all insured patients in that year 8 . While many of these pills were likely not used, prescription quantity alone has been shown to be associated with increased postoperative opioid use 3‐5 . Specifically, patients consume five additional pills for every 10 pills overprescribed 5,6 .…”

“…While many of these pills were likely not used, prescription quantity alone has been shown to be associated with increased postoperative opioid use 3‐5 . Specifically, patients consume five additional pills for every 10 pills overprescribed 5,6 . In addition to the individual risk of abuse and addiction, there is a significant risk to the greater community from excess prescriptions.…”