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)