A Prospective Analysis Of Opioid Prescription, Consumption, And Psychometric Correlations In Outpatient Plastic Surgery Procedures
Jouseph O. Barkho, MD, Cameron Leveille, Kyrillos M. Faragalla, Neil K. Sengupta, Chloe Wong, Forough Farrokhyar, Matthew C. McRae.
McMaster University, Hamilton, ON, Canada.
PURPOSE – The number of deaths due to opioid overdose is increasing annually in North America. Plastic Surgeons prescribe opioids after outpatient surgery based on anecdotal training rather than evidence; thus, excess opioid tablets may be available for diversion and abuse. The primary purpose of this study is to determine the factors predicting the decision to prescribe an opioid, and the secondary purpose is to determine the factors which predict the use of opioid tablets after outpatient Plastic Surgery procedures.
METHODS – Data was collected prospectively using two surveys: (1) one pre-operative and (2) post-operative at approximately day 14. Participants were included if they were over the age of 16, could provide their own consent, and underwent an outpatient procedure. The primary outcome was type of prescription given (opioid versus non-opioid). The secondary outcome was the number of opioid tablets consumed at the second survey. Additional information gathered included: demographic variables, the pain catastrophizing scale (PCS) and patient health questionnaire-4 (PHQ-4) for depression and anxiety. Statistical analyses included Chi-Square and student’s t-test for dichotomous and continuous variables respectively, univariable, and multivariate regression analysis. Alpha level was set to 0.05 for statistical significance.
RESULTS – Four hundred and fourty patients were recruited, of which 214 (49%) received an opioid prescription. The following factors were independently associated with receiving an opioid prescription: surgery of the upper limb (OR 4.0 [1.7-9.3], p=0.001), breast and abdomen (OR 11.1 [1.2-101.1], p=0.032), dermatologic surgery (OR 0.2 [0.1-0.5], p=0.001), and surgery in the main operating room (OR 23.6 [10.0-55.2], p<0.001). Patients consumed more opioid tablets if they were on pain medications prior to surgery (p=0.03), and if they scored higher on the PHQ-4 (p=0.002) but not the PCS (p=0.732). Plastic Surgeons prescribed significantly less opioids over time in minor procedures (p<0.001), without an increase in pain crises. The mean
number of tablets per opioid prescription was 22, and the mean number of tablets consumed per specific procedures were: 15.9 opioid tablets over 8.6 days after bilateral breast reduction, 8 tablets over 2.5 days after carpal tunnel release, 6.4 tablets over 3.3 days after palmar fasciectomy, 2.6 tablets over 5 days after trigger finger release, 2.1 tablets over 1.2 days after subcutaneous cyst or mass excision, and 1.2 tablets over 1.2 days after skin cancer surgery. The number of unused tablets were: 888 Tylenol 3, 156 Tylenol 2, 46 Oxycodone, 30 Percocet, and 24 hydromorphone. Only 18% of patients who received opioid prescriptions were instructed on proper disposal of unused tablets.
CONCLUSIONS – The patterns of opioid prescription and consumption patterns after outpatient Plastic Surgery are elucidated. Plastic surgeons globally over-estimate opioid requirements across all procedures studied. Surgeons could potentially prescribe less opioids in the minor procedure room without an increase in pain crises. Large sample, procedure-specific studies are required to determine opioid requirements. The lack of patient information on proper disposal of unused tablets represents a gap in knowledge which needs to be addressed.
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