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)