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.