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.