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.