\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Retrospective Cohort Study of Ibuprofen Based Pain Regimen to Reduce
Postoperative Opioid Use in Adult Tonsillectomy}



\author[1]{Antoinette Esce}%
\author[1]{Duncan Meiklejohn}%
\affil[1]{University of New Mexico Health Sciences Center}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives: Quantify the effect of a non-opioid pain regimen on
postoperative opioid prescriptions filled by the patient after adult
tonsillectomy. Design: Retrospective cohort study including a time frame
before and after a practice change from an opioid/acetaminophen-based
postoperative pain regimen to a regimen based on ibuprofen and
acetaminophen. Half of study subjects received a prescription for
postoperative opioid medications. Half were prescribed ibuprofen
following surgery and only provided with opioid analgesia as a rescue
medication, where ibuprofen was medically contraindicated, or at patient
request following counseling regarding risks of opioids. The New Mexico
Prescription Monitoring System was used to verify filled opioid
prescriptions. Descriptive statistics and logistic regression were used
for data analysis. Settings: Tertiary care academic medical center.
Participants: All elective adult tonsillectomies performed consecutively
by a single surgeon. Main Outcome Measures: Percent of patients filling
an opioid prescription. Results: Ninety-nine patients were included in
analysis. 53 received an opioid-based postoperative regimen and 46
received an ibuprofen/acetaminophen-based regimen. There was no
difference in the bleeding rate between the two groups. Significantly
fewer patients in the ibuprofen group filled postoperative opioid
prescriptions when compared to the group that did not receive ibuprofen
(40\% vs. 96.2\%, p\textless{}0.0001, OR=0.02). Conclusion: Ibuprofen is
a safe and effective analgesic following adult tonsillectomy and
significantly reduces the proportion of patients who fill a
postoperative opioid prescription.%
\end{abstract}%



\sloppy


\textbf{Abstract}

\textbf{Objectives:} Quantify the effect of a non-opioid pain regimen on
postoperative opioid prescriptions filled by the patient after adult
tonsillectomy.

\textbf{Design} : Retrospective cohort study including a time frame
before and after a practice change from an opioid/acetaminophen-based
postoperative pain regimen to a regimen based on ibuprofen and
acetaminophen. Half of study subjects received a prescription for
postoperative opioid medications. Half were prescribed ibuprofen
following surgery and only provided with opioid analgesia as a rescue
medication, where ibuprofen was medically contraindicated, or at patient
request following counseling regarding risks of opioids. The BLINDED FOR
REVIEW Prescription Monitoring System was used to verify filled opioid
prescriptions. Descriptive statistics and logistic regression were used
for data analysis.

\textbf{Settings} : Tertiary care academic medical center.

\textbf{Participants:} All elective adult tonsillectomies performed
consecutively by a single surgeon.

\textbf{Main Outcome Measures} : Percent of patients filling an opioid
prescription.

\textbf{Results:} Ninety-nine patients were included in analysis. 53
received an opioid-based postoperative regimen and 46 received an
ibuprofen/acetaminophen-based regimen. There was no difference in the
bleeding rate between the two groups. Significantly fewer patients in
the ibuprofen group filled postoperative opioid prescriptions when
compared to the group that did not receive ibuprofen (40\% vs. 96.2\%,
p\textless{}0.0001, OR=0.02).

\textbf{Conclusion:} Ibuprofen is a safe and effective analgesic
following adult tonsillectomy and significantly reduces the proportion
of patients who fill a postoperative opioid prescription.

\textbf{Keywords:} evidence based medicine, outcomes, tonsillectomy,
Health services research, pharmacology

\textbf{Key points:}

\begin{enumerate}
\tightlist
\item
  The opioid epidemic is an ongoing public health problem and
  prescription drug use continues to contribute.
\item
  Opioid prescriptions for post-operative analgesia varies widely.
\item
  Ibuprofen is safe and effective for adults following tonsillectomy.
\item
  An ibuprofen prescription significantly reduces the proportion of
  patients filling a post-operative opioid prescription following
  tonsillectomy.
\item
  The same post-operative ibuprofen prescription also reduced the amount
  of opioid prescribed.
\end{enumerate}

\textbf{Introduction}

The Centers for Disease Control (CDC) has classified the current crisis
of opioid abuse, misuse, and redirection as an epidemic.(1) Mortality in
the United States (US) from prescription drug overdose totaled 14,975
deaths in 2018, and actual fiscal costs have been estimated at close to
\$50 billion in the US alone.(2,3) According to the 2019 National Survey
on Drug Use and Health, 9.7 million people aged 12 or older reported
misusing prescription pain relievers in 2019. Over half of misusers
obtained their medication from a friend or relative, and 37.5\% obtained
them from a health care provider, either through a prescription or by
stealing.(4)

Postoperative pain prescriptions have been identified as an inciting
factor for opioid misuse, with longer durations of prescription
increasing the risk.(5--7) Multiple studies have demonstrated that
postoperative opioid prescriptions are variable even across similar
procedures, that overprescribing is common, and that the risk of
diversion is present.(8--13) Guidelines for safe prescribing in the
setting of chronic pain and long-term prescriptions are available
through the CDC, however there is a paucity of research on effective and
specific postoperative management with opioid-sparing regimens.(14)

Many common otolaryngologic surgeries are excellent candidates for
opioid-sparing regimens, as they are frequently outpatient and
associated with minimal or limited postoperative pain. The recent
clinical practice guideline from the American Academy of Otolaryngology
- Head and Neck Surgery (AAO-HNS) on ``Opioid Prescribing after Common
Otolaryngology Operations,'' strongly recommended that ``clinicians
should advocate for nonopioid medications as first-line management of
pain after otolaryngologic surgery.''(15) Despite this, multiple
misconceptions among otolaryngologists regarding the relative risks of
opioids and NSAIDs were reported in a recent systematic review.(16) In
this same study, Cramer et al found multimodal postoperative analgesia
with acetaminophen and a non-steroidal anti-inflammatory drug (NSAID) to
be safer and more effective than an opioid-based regimen. These findings
support other data showing NSAIDs to be at least equianalgesic to
opioid-based regimens and capable of reducing the need for narcotic
rescue medications.(17--19) Though there is a theoretical concern for
increased postoperative bleeding with NSAID use based on their
cyclooxygenase (COX) inhibitory activity, data do not support an
increased risk of bleeding with non-aspirin NSAIDs in adults.(20--22)
Additionally, the use of selective COX-2 inhibitors may reduce even this
theoretical risk.

Evaluating the impact of first line nonopioid postoperative analgesia on
the consumption of opioids was highlighted as a research need in the
AAO-HNS clinical practice guideline.(15) Adult tonsillectomy is an ideal
procedure for this type of evaluation, as it is commonly known to result
in significant postoperative pain, and practicing otolaryngologists
report the largest prescriptions of opioids for tonsillectomy when
compared to other adult otolaryngologic surgical procedures.(8,17) No
published literature to date has quantified the benefit of an
NSAID-based regimen on postoperative opioid requirement for adult
tonsillectomy.

\textbf{Objectives}

The purpose of our study was to quantify the effect of an NSAID-based,
non-opioid pain regimen on postoperative opioid prescriptions filled by
the patient.

\textbf{Methods}

\textbf{Ethical Considerations}

This study was approved by the Institutional Review Board at the BLINDED
FOR REVIEW. The data that support the findings of this study are
available from the corresponding author upon reasonable request. The
Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) Statement was used to guide reporting in this observational
study.

\textbf{Settings}

A tertiary care academic medical center in BLINDED FOR REVIEW United
States.

\textbf{Participants}

All elective adult tonsillectomies performed by a single surgeon between
June 2, 2017 and September 20, 2019.

\textbf{Main Outcome Measures}

The primary outcome was consumption of opioids, as indicated by a
patient filling any opioid prescription postoperatively, based on the
review of the BLINDED FOR REVIEW Prescription Monitoring Program (PMP)
online database. A secondary outcome was the initial dispensed quantity
of filled opioid prescriptions.

\textbf{Design}

All elective adult tonsillectomies performed by a single surgeon
(BLINDED FOR REVIEW) at a single institution between June 2, 2017 and
September 20, 2019 were reviewed. During this time, the surgeon
instituted a change in postoperative pain management for quality
improvement purposes. Prior to the change, patients were prescribed an
opioid analgesic and maximum safe dose of acetaminophen postoperatively
and counseled against using ibuprofen (Group 1). After the change,
patients were prescribed maximum safe doses of acetaminophen and
ibuprofen and counseled by the surgeon about the risks of opioid
analgesics (Group 2). For patients in Group 2, opioids were only
prescribed as postoperative rescue medications, if NSAID was
contraindicated due to an allergy or medical condition, or if
specifically requested by the patient preoperatively after receiving
counseling on opioid risks and the benefits of an NSAID-based regimen.
No patient in either group was denied a prescription for opioid
medications if they specifically requested them preoperatively, or if
they felt their pain was not adequately controlled postoperatively. All
tonsillectomies were performed using a ``cold'' technique without
electrocautery or Coblation. Exclusion criteria included pediatric
patients less than 18 years of age at the time of surgery, patients
undergoing tonsillectomy for malignancy, and patients undergoing
additional procedures such as uvulopalatopharyngoplasty or
adenoidectomy.

The primary intervention in this study was the postoperative
prescriptions for ibuprofen and acetaminophen. The secondary
intervention was counseling regarding the risks of opioid analgesics and
the benefits of a non-opioid pain regimen. Additional information
collected via chart review included patient demographic information,
comorbidities as defined by the patient's American Society of
Anesthesiologists (ASA) Physical Status Score, procedure information,
pathology results, relevant patient history related to substance abuse,
opioid misuse, chronic pain, or anxiety/depression, any medical
contraindications to ibuprofen or acetaminophen, any reported adverse
effects from pain medications, and any complications related to the
surgical procedure.

Information regarding filled perioperative opioid prescriptions as well
as dose and duration was extracted from the PMP website. A waiver was
provided by the BLINDED FOR REVIEW Board of Pharmacy to permit use of
de-identified information from the PMP website for the purposes of this
research study. The website was searched for the patient's identifying
information including any known previous names or aliases, and any
prescription of any controlled substance tracked by the PMP was recorded
for a time period ranging from one month prior to the surgical date to
three months after the surgical date. The PMP database was searched for
patient records for all states and non-state medical systems
participating in the online database (33 of 50 US states, as well as the
US Military Health System and Puerto Rico).

Simple student t-tests of two proportions for binary data or
nonparametric Mann-Whitney U tests for continuous data were used to
compare the primary outcomes and other relevant characteristics between
Groups 1 and 2. A subgroup analysis was performed on Group 2 to compare
relevant patient factors between those who received ibuprofen and filled
an opioid prescription and those who received ibuprofen and did not fill
an opioid prescription, though the study was not properly powered to
detect a difference in this subgroup. A nonparametric Mann-Whitney U
test was used to compare the average initial prescribed opioid dose
between groups, as these were not normally distributed. Finally, a
multiple logistic regression was designed to evaluate the independent
effect of an ibuprofen prescription and counseling on opioid
prescription filling while controlling for age, race, and a history of
opioid use, substance abuse, chronic pain, or anxiety/depression.

\textbf{Results}

Ninety-nine patients were identified and included in the analysis. Group
1 contained 53 patients who received a routine postoperative opioid
prescription and counseling against ibuprofen use. Group 2 contained 46
patients who received an ibuprofen prescription and counseling regarding
the risks of opioid medications. Population level data on various
characteristics for each of these groups can be found in Table 1. There
was no statistically significant difference in age, ASA score, opioid
use, chronic pain, or anxiety/depression between the two groups.
Pathology from all cases was consistent with either inflammatory
tonsillitis and/or benign tonsillar hypertrophy.

Outcomes are reported in Table 2. Fifty-one of the 53 patients (96.2\%)
in Group 1 filled a postoperative opioid prescription. Only 18 of the 46
patients (40.0\%) in Group 2 filled a postoperative opioid prescription,
which was significantly fewer than Group 1 (p\textless{}0.001). Sixteen
of these 18 patients (88.9\%) filled an opioid prescription on
postoperative day zero or one. Six of these patients had requested
opioids during their preoperative visit.

When averaged to a standard cohort of 50 patients, an ibuprofen
prescription and preoperative counseling resulted in a 66.5\% reduction
in the amount of opioid prescribed for tonsillectomy. The average first
quantity of opioid dispensed in morphine equivalents for the patients in
Group 1 was 215mg \selectlanguage{ngerman}± 113mg, which is the equivalent of approximately
143mg of oxycodone. The average first quantity of opioid dispensed in
morphine equivalents for the patients in Group 2 was 167mg ± 122.5mg,
which is the equivalent of approximately 111mg of oxycodone, and
significantly less than Group 1 (p=0.04). Based on the data in this
study, 50 patients undergoing tonsillectomy without ibuprofen would
collectively use 10,300mg in morphine equivalents. This translates to
6,867mg of oxycodone or 1,373 5mg tablets. On the other hand, 50
patients undergoing tonsillectomy with an ibuprofen prescription would
collectively use 3,450mg in morphine equivalents. This translates to
2,300mg of oxycodone or 460 5mg tablets.

A subgroup analysis of Group 2 did not find any difference in age, race,
or relevant patient factors between those who received ibuprofen and
filled an opioid prescription and those who received ibuprofen and did
not fill an opioid prescription. There was no statistically significant
difference in bleeding rates between Groups 1 and 2 (5.3\% vs 2.2\%,
p=0.42), though this study was not powered to detect any such
difference.

A multiple logistic regression controlling for age, race, and a history
of opioid use, substance abuse, chronic pain, or anxiety/depression was
designed to assess the ability of an ibuprofen prescription to
independently predict the likelihood of a filled postoperative opioid
prescription. The only statistically significant independent predictor
was an ibuprofen prescription, which significantly reduced the odds of a
patient filling a postoperative opioid prescription (OR = 0.02, 95\% CI
0.003, 0.09, p \textless{} 0.001).

\textbf{Discussion}

The opioid crisis continues to undermine public health in the US, with
prescription narcotics accounting for a large proportion of abuse and
misuse. Current published research strongly suggests that perioperative
prescribing of opioids is a significant factor in this crisis. Surgeons
have been reported as being the second largest prescribers of opioids in
this country,(23) and as such have a unique opportunity to reduce
overall opioid misuse. This retrospective cohort study of a single
provider's practice change confirms the benefit of preoperative
counseling and a structured, non-opioid based postoperative pain regimen
in reducing opioid prescriptions after adult tonsillectomy.

The risks of perioperative opioid prescriptions are well documented.
Based on a 2018 AAO-HNS survey, 37 tablets or one week's worth of opioid
medication were prescribed on average following adult tonsillectomy,
with substantial variability.(8) This amount correlates with the 15\%
theoretical risk of long-term opioid use with a one week initial
prescription reported by the CDC, with the risk accelerating around 3
days and increasing steadily the longer the initial prescription.(7) In
addition to the risk of dependence and abuse for the patient, there is
also increased community harm from overprescribing of opioids. Many
postoperative opioid prescriptions are not used or are overprescribed,
creating potential for diversion and abuse.(9--13)

The recent clinical practice guideline from the AAO-HNS released in
April 2021 discusses the role of opioid analgesics in postoperative
otolaryngologic surgical care and makes several recommendations,
including a strong recommendation for the use of nonopioid analgesia
whenever possible following surgery. This guideline also emphasized the
importance of reducing the number of extra opioids available after
surgery.(15) Our study is the first to quantify the effect of a simple
practice change in reducing the number of filled opioid prescriptions,
thus limiting both patient exposure to opioids as well as the number of
extra opioids available in the community for misuse or diversion.

A major strength of this study is a clear intervention with two
comparable cohort groups. Though it was not randomized or prospective,
provider, procedural technique and hospital factors were consistent, and
there was no opportunity for selection bias as the groups were instead
split temporally. Though an NSAID-based pain regimen was the main
intervention in this study, it is important to note that the
prescription was not provided in a vacuum. Changing the default
postoperative pain prescription from opioids to ibuprofen required a
change in preoperative counseling, which highlighted the risks of
opioids and the safety and effectiveness of ibuprofen. This intervention
alone may have reduced opioid use postoperatively and likely increased
the efficacy of the ibuprofen prescription in preventing opioid use
postoperatively.

One weakness of this study was the limitation of our primary outcome
variable. While the PMP reports filled opioid prescriptions, it does not
track the quantity of medication used by the patient or leftover
dispensed medication. Additionally, our study did not assess
postoperative pain control or medication side effects, as we were unable
to quantify or detail a true side effect rate for analgesic medications
based solely on chart review.

Interestingly, for those patients who received an opioid prescription,
the initial amount prescribed was significantly lower in Group 2, though
variability remained high. It is possible that the practice change or
other external factors (such as increased awareness of the opioid
crisis) affected the prescribing patterns of providers on the surgical
team, leading to reduced initial quantity prescribed. This type of
effect correlates with recent research showing reduced postoperative
opioid prescribing from external forces such as regulatory changes,
implementation of prescription monitoring programs, or implementation of
targeted counseling.(24,25)

\textbf{Conclusion}

Providing a prescription for ibuprofen following adult tonsillectomy
along with counseling about the risks of opioid medications
significantly decreases the number of filled opioid prescriptions and
the initial dose of opioid prescriptions. Further research is necessary
to determine otolaryngology specific risk factors for prolonged opioid
use following common procedures.

\textbf{References}

1. Understanding the Epidemic \textbar{} Drug Overdose \textbar{} CDC
Injury Center {[}Internet{]}. 2021 {[}cited 2021 Apr 12{]}. Available
from: https://www.cdc.gov/drugoverdose/epidemic/index.html

2. Wilson N. Drug and Opioid-Involved Overdose Deaths --- United States,
2017--2018. MMWR Morb Mortal Wkly Rep {[}Internet{]}. 2020 {[}cited 2021
Apr 12{]};69. Available from:
https://www.cdc.gov/mmwr/volumes/69/wr/mm6911a4.htm

3. Oderda GM, Lake J, Rüdell K, Roland CL, Masters ET. Economic Burden
of Prescription Opioid Misuse and Abuse: A Systematic Review. J Pain
Palliat Care Pharmacother. 2015 Oct 2;29(4):388--400.

4. Lipari RN. Key Substance Use and Mental Health Indicators in the
United States: Results from the 2019 National Survey on Drug Use and
Health. 2019;114.

5. Brat GA, Agniel D, Beam A, Yorkgitis B, Bicket M, Homer M, et al.
Postsurgical prescriptions for opioid naive patients and association
with overdose and misuse: retrospective cohort study. BMJ. 2018 Jan
17;360:j5790.

6. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et
al. New Persistent Opioid Use After Minor and Major Surgical Procedures
in US Adults. JAMA Surg. 2017 Jun 21;152(6):e170504.

7. Shah A. Characteristics of Initial Prescription Episodes and
Likelihood of Long-Term Opioid Use --- United States, 2006--2015. MMWR
Morb Mortal Wkly Rep {[}Internet{]}. 2017 {[}cited 2019 Sep 19{]};66.
Available from: https://www.facebook.com/CDCMMWR

8. Schwartz MA, Naples JG, Kuo C-L, Falcone TE. Opioid Prescribing
Patterns among Otolaryngologists. Otolaryngol Neck Surg. 2018
May;158(5):854--9.

9. Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption
following outpatient upper extremity surgery. J Hand Surg. 2012
Apr;37(4):645--50.

10. Patel S, Sturm A, Bobian M, Svider PF, Zuliani G, Kridel R. Opioid
Use by Patients After Rhinoplasty. JAMA Facial Plast Surg. 2018 Jan
1;20(1):24--30.

11. Hill MV, McMahon ML, Stucke RS, Barth RJ. Wide Variation and
Excessive Dosage of Opioid Prescriptions for Common General Surgical
Procedures. Ann Surg. 2017;265(4):709--14.

12. Bartels K, Mayes LM, Dingmann C, Bullard KJ, Hopfer CJ, Binswanger
IA. Opioid Use and Storage Patterns by Patients after Hospital Discharge
following Surgery. PloS One. 2016;11(1):e0147972.

13. Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription
Opioid Analgesics Commonly Unused After Surgery: A Systematic Review.
JAMA Surg. 2017 Nov 1;152(11):1066--71.

14. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S,
Brennan T, et al. Management of Postoperative Pain: A Clinical Practice
Guideline From the American Pain Society, the American Society of
Regional Anesthesia and Pain Medicine, and the American Society of
Anesthesiologists' Committee on Regional Anesthesia, Executive
Committee, and Administrative Council. J Pain. 2016 Feb 1;17(2):131--57.

15. Anne S, Mims J ``Whit,'' Tunkel DE, Rosenfeld RM, Boisoneau DS,
Brenner MJ, et al. Clinical Practice Guideline: Opioid Prescribing for
Analgesia After Common Otolaryngology Operations. Otolaryngol Neck Surg.
2021 Apr 1;164(2\_suppl):S1--42.

16. Cramer JD, Barnett ML, Anne S, Bateman BT, Rosenfeld RM, Tunkel DE,
et al. Nonopioid, Multimodal Analgesia as First-line Therapy After
Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory
Drugs (NSAIDs). Otolaryngol Neck Surg. 2021 Apr 1;164(4):712--9.

17. Tolska HK, Hamunen K, Takala A, Kontinen VK. Systematic review of
analgesics and dexamethasone for post-tonsillectomy pain in adults. Br J
Anaesth. 2019 Aug 1;123(2):e397--411.

18. Salonen A, Kokki H, Nuutinen J. Recovery After Tonsillectomy in
Adults: A Three\selectlanguage{english}-Week Follow\selectlanguage{english}-up Study. The Laryngoscope. 2002 Jan
1;112(1):94--8.

19. Moiniche S, Romsing J, Dahl JB, Tramer MR. Nonsteroidal
Antiinflammatory Drugs and the Risk of Operative Site Bleeding After
Tonsillectomy: A Quantitative Systematic Review. Anesth Analg. 2003
Jan;96(1):68.

20. Krishna S, Hughes LF, Lin SY. Postoperative hemorrhage with
nonsteroidal anti-inflammatory drug use after tonsillectomy: a
meta-analysis. Arch Otolaryngol Head Neck Surg. 2003
Oct;129(10):1086--9.

21. Stokes W, Swanson RT, Schubart J, Carr MM. Postoperative Bleeding
Associated with Ibuprofen Use after Tonsillectomy: A Meta-analysis.
Otolaryngol Neck Surg. 2019 Nov 1;161(5):734--41.

22. Riggin L, Ramakrishna J, Sommer DD, Koren G. A 2013 updated
systematic review \& meta\selectlanguage{english}-analysis of 36 randomized controlled trials;
no apparent effects of non steroidal anti\selectlanguage{english}-inflammatory agents on the
risk of bleeding after tonsillectomy. Clin Otolaryngol. 2013 Apr
1;38(2):115--29.

23. Cramer JD, Wisler B, Gouveia CJ. Opioid Stewardship in
Otolaryngology: State of the Art Review. Otolaryngol--Head Neck Surg Off
J Am Acad Otolaryngol-Head Neck Surg. 2018 May;158(5):817--27.

24. Rubin S, Wulu JA, Edwards HA, Dolan RW, Brams DM, Yarlagadda BB. The
Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology
Surgeries. Otolaryngol Neck Surg. 2021 Apr 1;164(4):781--7.

25. Banik GL, Kraimer KL, Shindo ML. Opioid Prescribing in Patients
Undergoing Neck Dissections With Short Hospitalizations. Otolaryngol
Neck Surg. 2021 Apr 1;164(4):792--8.

\textbf{Table 1.} Descriptive population statistics\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Total} \textbf{(N=99)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group 1} \textbf{Opioid Rx + No Ibu} \textbf{(N=53)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group 2} \textbf{Ibu Rx + No Opioid} \textbf{(N=46)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{p-value}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Sex}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Female (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
68 (68\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35 (66\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
33 (72\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NS\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Age (years)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29.4 (\selectlanguage{ngerman}±10.8)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
30.2 (\selectlanguage{ngerman}±11.1)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28.6 (\selectlanguage{ngerman}±10.4)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NS\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Race/Ethnicity\\
}Hispanic (\%) Native (\%) White (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
57 (58\%) 6 (6\%) 24 (24\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
32 (60\%) 5 (9\%) 11 (21\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
25 (54\%) 1 (2\%) 13 (28\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NS NS NS\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Average ASA Score}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.9 (\selectlanguage{ngerman}±0.6)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.9 (\selectlanguage{ngerman}±0.6)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.8 (\selectlanguage{ngerman}±0.7)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NS\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Relevant Patient Factors\\
}History of opioid use History of chronic pain History of
anxiety/depression\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (2\%) 17 (17\%) 31 (31\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (4\%) 11 (21\%) 17 (32\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0\%) 6 (13\%) 17 (32\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NS NS NS\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Descriptive characteristics for each study group. SD is standard
deviation. There were no statistically significant differences between
the two groups in terms of demographics or risk factors for opioid use.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 1} \textbf{Opioid Rx + No Ibu} \textbf{(N=53)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 2} \textbf{Ibu Rx + No Opioid} \textbf{(N=46)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{{[}2{]}p-value}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Filled an opioid Rx}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Count (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
51 (96.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
18 (40.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Average initial opioid dose (mg)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
215 (\selectlanguage{ngerman}±113)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
167 (\selectlanguage{ngerman}±122.5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.04\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Primary and secondary outcomes

Summary statistics for the primary and secondary outcomes. SD is
standard deviation. Fewer opioid prescriptions for less narcotic per
prescription were filled by the group who received an ibuprofen
prescription.

\textbf{Hosted file}

\verb`Table1.docx`  available at \url{https://authorea.com/users/736559/articles/712140-retrospective-cohort-study-of-ibuprofen-based-pain-regimen-to-reduce-postoperative-opioid-use-in-adult-tonsillectomy}

\textbf{Hosted file}

\verb`Table2.docx`  available at \url{https://authorea.com/users/736559/articles/712140-retrospective-cohort-study-of-ibuprofen-based-pain-regimen-to-reduce-postoperative-opioid-use-in-adult-tonsillectomy}

\selectlanguage{english}
\FloatBarrier
\end{document}

