Abstract
This data analysis examines electronic medical records and a state prescription registry to investigate the prescription patterns for opioids in patients who have undergone rhinoplasty to manage pain in the 3 weeks after surgery.
The opioid epidemic is drawing national attention because opioid-related deaths have increased 200% since 2000.1 The epicenter of the epidemic is the United States, where 4.7% of the world’s population consumes two-thirds of the world’s opiate supply.2 Most persons who abuse opioid drugs are not the intended recipient of the opioids, and more than half of abusers receive pills through friends and family. Therefore, surgeon prescribers play an important role.3 Rhinoplasty is one of the most common procedures performed by facial plastic surgeons, and managing postoperative rhinoplasty pain without contributing to the opioid epidemic is imperative. There are currently few studies examining postrhinoplasty opioid needs based on patient survey data4 but ours is the first, to our knowledge, to use a statewide electronic opioid registry.
Methods
A retrospective review of 173 patients who underwent rhinoplasty by 2 board-certified facial plastic surgeons (L.N.L. and D.A.S.) between April 1, 2017, and April 1, 2018, at a tertiary care hospital was performed. For this study, cases of cosmetic rhinoplasty and functional open septorhinoplasty with structural grafting were included.5 Electronic medical records were queried for demographic information and procedural details, including primary or revision surgery, autologous cartilage graft harvest, and concurrent sinus surgery. Opioid prescription data were recorded, including type of opioid, quantity, dosage, and refills required within 3 weeks of surgery. The Massachusetts Prescription Awareness Tool, a statewide opioid registry that allows prescribers to determine a patient's prescribing history, was interrogated to determine if refills were prescribed from outside sources, such as the patient’s primary care physician or emergency department physician, or if partial refills were performed. Mean quantity of tablets prescribed was compared by case type (revision vs primary), autologous grafting, and age (younger than 40 years vs 40 years or older). Institutional review board approval was obtained from Massachusetts Eye and Ear, and patient consent was not required because all registry data were deidentified.
Results
A total of 173 rhinoplasties were performed during the 1-year study period. Sixty-three of the procedures (33.5%) included a cosmetic component, and 115 (66.5%) were purely functional. The mean (SD) patient age was 37.5 (15.2) years, and 92 (53.2%) of the patients were women. Concurrent sinus surgery was performed in 17 (9.8%) cases.
Of the 173 patients, 168 (97.1%) were prescribed opioids in addition to acetaminophen. A mean (SD) of 28 (11.4) tablets were prescribed per patient (range, 5-40 tablets). Among the 168 patients prescribed an opioid, 147 (87.5%) received oxycodone, and of the remaining 21 patients, 12 (7.1%) were prescribed oxycodone-acetaminophen; 7 (4.2%), hydrocodone-acetaminophen; 1 (0.6%), acetaminophen-codeine (n = 1 [0.6%]); and 1 (0.6%), tramadol. Nineteen patients (11.3%) did not fill their narcotic prescription. Refills within 3 weeks of surgery were rare (n = 2 [1.2%]). Of the 2 patients who required refills, 1 underwent revision rhinoplasty with conchal cartilage and was prescribed 40 oxycodone tablets, and the other underwent primary rhinoplasty without extranasal grafting and was prescribed 5 tablets of oxycodone-acetaminophen.
Overall, there was no significant difference in the mean number of tablets prescribed when stratified by age, sex, primary vs revision rhinoplasty, type of rhinoplasty, or concurrent sinus surgery. However, patients with conchal cartilage harvest were prescribed significantly more tablets (36 with harvest vs 24 without).
Discussion
Despite a wide range in the number of opioid tablets prescribed, refills were exceedingly rare, including among patients who were prescribed as few as 5 tablets. The Massachusetts Prescription Awareness Tool state registry confirmed that patients were not routinely receiving refills from other prescribers outside the institution where they received their prescriptions. Although the optimal number of tablets required to manage postoperative rhinoplasty pain is unclear; these data suggest that patients experienced less pain than was anticipated.
With the current opioid epidemic, the onus is on surgeons to critically examine postoperative pain management practices. The near-negligible refill rate of prescriptions in the present study, confirmed by the Massachusetts State Registry database, suggests that the optimal number of tablets may be lower than expected. Further study to optimize postrhinoplasty pain management without contributing to the opioid epidemic is warranted.
References
- 1.Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382. doi: 10.15585/mmwr.mm6450a3 [DOI] [PubMed] [Google Scholar]
- 2.Demsey D, Carr NJ, Clarke H, Vipler S. Managing opioid addiction risk in plastic surgery during the perioperative period. Plast Reconstr Surg. 2017;140(4):613e-619e. doi: 10.1097/PRS.0000000000003742 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug Alcohol Rev. 2011;30(3):264-270. doi: 10.1111/j.1465-3362.2011.00291.x [DOI] [PubMed] [Google Scholar]
- 4.Patel S, Sturm A, Bobian M, Svider PF, Zuliani G, Kridel R. Opioid use by patients after rhinoplasty. JAMA Facial Plast Surg. 2018;20(1):24-30. doi: 10.1001/jamafacial.2017.1034 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty. Otolaryngol Head Neck Surg. 2017;156(2_suppl):S1-S30. doi: 10.1177/0194599816683153 [DOI] [PubMed] [Google Scholar]