Changes in Opioid Prescribing Habits for Patients Undergoing Rhinoplasty and Septoplasty

Key Points

Question

Has there been a decrease in the amount of opioids prescribed to patients following rhinoplasty and/or septoplasty since the Vermont opioid prescribing legislation took effect on July 1, 2017, and if so, are patients experiencing more postoperative pain?

Findings

In this case-control study of 80 adults, the mean number of opioid pills prescribed to patients after the Vermont opioid prescribing legislation decreased from 17.5 to 9.7, which was associated with a statistically significant decrease in the mean morphine milligram equivalents that were prescribed (130.9 to 73.2). There was no statistically significant difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit.

Meaning

Since there was no increase in patients' complaints about postoperative pain or a need for a second prescription after surgery, the decreased amount of opioids prescribed seems sufficient for pain control.

Abstract

Importance

Opioid prescriptions have increased substantially over the last 2 decades, contributing to the opioid epidemic. Physician practices and legislative changes play a key role in decreasing prescription opioid use.

Objective

To evaluate changes in opioid prescribing habits for patients undergoing rhinoplasty and/or septoplasty before and after the adoption of new opioid legislation.

Design, Setting, and Participants

This single-institution case-control study examined opioid prescribing habits for 80 patients who were undergoing rhinoplasty and septoplasty with or without turbinate reduction at the University of Vermont between March 2016 and May 2018. Patients were excluded if they underwent concomitant endoscopic sinus surgery or were younger than 14 years. Patients were divided by surgery date before or after legislative changes on July 1, 2017.

Exposures

Rhinoplasty and septoplasty with or without turbinate reduction.

Main Outcomes and Measures

Patient demographics and opioid prescriptions were recorded. Patients were evaluated if they reported pain during follow-up, called the office, or received a second prescription. The Vermont Prescription Monitoring System was queried to determine if opioid prescriptions were filled within 30 days of the procedure. The 2 groups were compared to test the hypothesis that opioid prescriptions had decreased after legislative changes.

Results

Of a total of 80 participants, the mean (SD) age in the before (15 women [37.5%]) and after (16 women [40.0%]) groups were 41.4 years and 40.6 years, respectively. There was a statistically significant decrease in the number of pills prescribed to the after group (17.5 to 9.7; P < .001) as well as a decrease in the morphine milligram equivalents that were prescribed (130.9 to 73.2; P < .001). There was no statistical difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit.

Conclusions and Relevance

Recent laws in Vermont regarding opioid prescribing were implemented in 2017 to curb the ongoing opioid epidemic. Our observations of patients undergoing septoplasties and rhinoplasties found a significant reduction in opioid prescriptions. This was not associated with an increase in patient complaints about postoperative pain or the need for a second prescription after surgery. This shows that we may safely be able to decrease the number of narcotic medications that we prescribe.

Level of Evidence

3.

This case-control study evaluates changes in opioid prescribing habits for patients in Vermont undergoing rhinoplasty and/or septoplasty before and after the adoption of new statewide opioid legislation.

Introduction

Over the last 2 decades, the prescription of opioids has increased substantially, contributing to the opioid epidemic that has developed into a public health emergency.¹ On average, more than 130 Americans die every day from an opioid overdose.² In Vermont, the annual number of opioid-related deaths nearly tripled from 2010 to 2018.³ In an effort to curb the amount of opioids prescribed, the Vermont Department of Health passed the Rule Governing the Prescribing of Opioids for Pain on July 1, 2017, that limited the amount of opioids that can be prescribed for acute pain.⁴ When prescribing opioids, the new laws require providers to check the Vermont Prescription Monitoring System (VPMS), provide patient education regarding the risks of taking opioids, obtain signed informed consent, and prescribe medications based on established new standards for pain to ensure that patients receive the fewest number of pills necessary for the shortest duration possible.⁴ In this study, we observed changes in prescriber habits and their association with pain control for patients who underwent a septoplasty or rhinoplasty before and after July 1, 2017.

Methods

A retrospective case-control study was performed on 80 consecutive patients who underwent a rhinoplasty and/or septoplasty with or without turbinate reduction at the University of Vermont Medical Center. This study was reviewed by the University of Vermont institutional review board; it was approved for an exemption and consent was not obtained because we used existing data in a deidentified manner. Patients were divided into 2 groups, with 40 (50.0%) undergoing surgery before the opioid legislation changed on July 1, 2017, and 40 (50.0%) undergoing surgery after. There were 5 surgeons that performed all of the procedures in both groups. Internal nasal splints were used for all patients who underwent septoplasty. Patients who underwent osteotomies during their rhinoplasty also underwent external splint placement. Patients were included in the study if they were older than 14 years and did not undergo any other procedures at the time of surgery. Information was collected on whether patients were taking opioids before surgery, the number of pills taken, the type of opioid prescribed the day of surgery, and if they had inadequate pain control postoperatively. A query was conducted using the VPMS to determine if the patient filled the prescription. Patients were asked whether their pain control was sufficient at their first postoperative visit. It was also noted if a patient called the office regarding pain or required a second prescription. The number of opioid pills prescribed was tabulated and the morphine milligram equivalents (MMEs) were calculated to normalize the opioid dose among the various narcotic types. Statistical analyses were performed using SPSS, version 25 (IBM), and t tests were used to compare the 2 groups, with significance set at P < .05.

Results

The mean (SD) age of the group before legislation was 41 (15) years and included 25 men (62.5%) and 15 women (37.5%), 4 (10.0%) of whom were taking opioid medication before undergoing surgery. The mean (SD) age of the group after legislation was also 41 (17) years and included 24 men (60.0%) and 16 women (40.0%), with 1 patient (2.5%) taking opioid medication before undergoing surgery (Table 1). There were no significant differences in age, sex, or history of opioid use between the 2 groups. Before legislation, a mean (SD) of 18.2 (8.4) pills or 130.9 (74) MME were given postoperatively vs a mean (SD) of 9.7 (3.1) pills or 73.1 (24) MME after legislation, which was statistically significant (P < .001). There was no significant difference in the number of telephone calls received for pain or complaints of pain at the postoperative visit. When looking at the VPMS registry, 2 patients (5.0%) did not fill their opioid prescription prelegislation vs 4 patients (10.0%) postlegislation. Furthermore, the number of second prescriptions before legislation vs after legislation was not statistically different (3 [7.5%] and 4 [10.0%], respectively) (Table 2).

Table 1. Patient Demographics.

Characteristic	Legislation		P Value
	Before (n = 40)	After (n = 40)
Age, mean (SD), y	41.4 (15)	40.6 (17)	.82
Sex, No. (%)
Men	25 (62.5)	24 (60.0)	.83
Women	15 (37.5)	16 (40.0)
Patient taking preoperative opioids, No.	4	1	.18
Procedures, No. (%)
Septoplasty	25 (62.5)	25 (62.5)	NA
Septorhinoplasty	12 (30.0)	13 (32.5)
Rhinoplasty	3 (7.5)	2 (5.0)

Abbreviation: NA, not applicable.

Table 2. Opioids Prescribed Before and After Legislation.

Characteristic	Legislation		P Value
	Before (n = 40)	After (n = 40)
Mean No. of pills prescribed	18.2	9.7	<.001
Mean MMEs	130.9	73.1	<.001
Second prescriptions given	2	4	.16
Telephone calls for pain	5	6	.32
Pain at postoperative visit	3	3	>.99

Abbreviation: MMEs, morphine milligram equivalents.

Discussion

Recently, the rate of opioid overdose has increased markedly, leading the federal government to declare a state of emergency.¹ To address this problem in Vermont, lawmakers and physicians worked together to pass legislation. The Rule Governing the Prescribing of Opioids for Pain was passed on July 1, 2017, and aimed to decrease the number of opioids that could be prescribed for pain.⁴

The mean (SD) number of pills prescribed in the before group was 18.2 (9.4). This was similar to what was found in a study by Schwartz et al.⁵ They performed a nationwide survey-based study of otolaryngologists and their prescribing habits. Their study found the mean number of pills prescribed to patients undergoing septoplasty or rhinoplasty to be 19 and 22, respectively.

As a result of legislation, the number of pills prescribed in this study decreased by 45%. Despite the significant decrease in the number of pills prescribed in this study, there was no associated increase in the number of patients returning to the clinic or going to the emergency department because of inadequate pain control. The overall rate of a needing a second prescription was less than 10%.

Part of the opioid rules require discussing the risks with patients and providing them with written information about opioids. The conversation also leads to more recommendations about nonopioid analgesics as the primary source for pain control. For those patients who were able to take acetaminophen and ibuprofen, it was recommended that they take those as first-line analgesia and reserve the opioid prescription as a rescue medication. This requirement led to some patients at our institution declining their use of opioids postoperatively. While it trended toward but did not reach statistical significance, there were 4 patients (10.0%) in the after legislation group who did not fill their prescription for pain medications compared with only 2 (5.0%) before legislation. The trend toward significance was limited by the sample size and the association could be more thoroughly evaluated in a larger study.

Limitations

This study is limited by being retrospective. We are unable to determine from the data how many pills patients actually consumed. Patients who reported that they had taken all of the prescribed tablets but had persistent pain were given a second prescription for opioids.

Although we were unable to evaluate this directly in this retrospective review, previous studies have found that patients who underwent outpatient surgery took 50% or less of their prescribed postoperative opioid medication.^6,7 Dang et al⁸ found that patients who underwent otolaryngologic surgery took less than half of their prescribed opioids. For patients who underwent rhinoplasty, Patel et al⁹ found that they only took 36% of the opioids prescribed.

In this study’s patient population, postoperative pain was still adequately controlled with the decreased number of pills prescribed. Even if patients were taking more of the pills that were prescribed, given the reduction from 18.2 pills to 9.7 pills, this still resulted in a similar number or fewer overall pills used. Furthermore, this leaves fewer pills available for inappropriate use or diversion.

Another limitation of this study is that the data were restricted to 80 patients and the prescribing habits of 5 surgeons. We are currently performing a more comprehensive evaluation of patients’ opioid usage and needs and physician prescribing habits in a prospective study to evaluate the best practice for prescribing postoperative opioids.

Conclusions

This study presents evidence of an association between new policies that reduce the quantity of opiates prescribed to patients and uncompromised pain management. The size and scale of the opioid epidemic is such that it will need the actions of clinicians and lawmakers working together to find solutions for the growing problem.