A 2017 Dartmouth study that looked at opioid use after five common surgeries (partial mastectomy, partial mastectomy with sentinel lymph node biopsy, laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, and open inguinal hernia repair) found that patients took just 28% of the opioids they were prescribed (Ann Surg. 2017;265:709–714).
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December 2017Noting the data, Dartmouth provided physician education and recommended that surgeons encourage patients to use a nonsteroidal anti-inflammatory drug (NSAID) and acetaminophen before using opioids. A subsequent study found a 53 percent reduction in the number of pills prescribed for the same five surgeries, with adequate pain control maintained (Ann Surg. [Published online ahead of print March 6, 2017]).
Though the Dartmouth study didn’t include any otolaryngology surgeries, available evidence suggests that it’s safe—and prudent—to substitute NSAIDs for some opioids for post-surgical pain. Children undergoing tonsillectomy, for instance, used to routinely receive acetaminophen with codeine for pain control. Today, post-op pediatric tonsillectomy pain control typically involves plain acetaminophen and ibuprofen—sometimes combined with scheduled steroid doses and intermittent opioid use (a dose scheduled for the post-op day when pain is likely to be most intense).
“I think the message for otolaryngologists is that they really should avoid using opioids unless it’s absolutely necessary, and in many cases, it really isn’t necessary,” Dr. Kolodny said.
Be cautious even when prescribing opioids to people with cancer. A 2017 study published in Cancer found that opioid use is more common in cancer survivors, even those five and 10 years into remission, than in people without a history of cancer (Cancer. 2017;123:4286-4293), and a 2017 study of patients undergoing surgery for head and neck cancer found that nearly a quarter of patients who did not use opioids prior to surgery developed a chronic use pattern after surgery (JAMA Otolaryngol Head Neck Surg. 2017; E1–E8).
4. Patient Education Regarding Proper Use (and Disposal) of Opioids Is Necessary
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Establishing realistic expectations regarding pain control is crucial. Patients need to know that some discomfort is normal, and that opioids can’t eliminate all post-operative discomfort. Post-surgical headaches, for instance, are often related to dehydration or caffeine withdrawal, and are better treated with a glass of water or cup of coffee.
It’s also important to discuss “peak intervals when the pain is going to be the worst,” Dr. Moche said. A patient who expects more pain on post-op day four compared to post-op day one is better equipped to deal with the pain, particularly if you also discuss a variety of pain control strategies, including the use of non-opioid medications.