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Opioid prescription post-surgical strategy

Article-Opioid prescription post-surgical strategy

Woman nose surgery

Studies published this year suggest prescribing 20, 30 or more opioid pills post-rhinoplasty might be significantly more than most patients need. And by limiting the number of opioids they prescribe after rhinoplasty, surgeons might contribute to the greater good of decreasing opioid-related addiction and death.

In a retrospective review of 173 cosmetic and functional rhinoplasty patients, facial plastic surgeons report prescribing an average 28 tablets, ranging from 5 to 40 for each patient. They found more than 11% of patients didn’t fill their narcotic prescriptions. Only two patients required refills, according to the research letter published September 6, 2018, in JAMA Facial Plastic Surgery.1

“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,” the authors write. “With the current opioid epidemic, the onus is on surgeons to critically examine postoperative pain management practices.”

A study evaluating 62 rhinoplasty patients that was published in January-February 2018 in JAMA Facial Plastic Surgery suggests overprescribing is a reality and offers an optimal post-rhinoplasty prescribing regimen.2 The case series analysis reveals that while facial plastic surgeons initially prescribed 20 to 30 hydrocodone-acetaminophen combination tablets, patients used only an average 8.7 tablets, or 40% of those prescribed after surgery. Nearly three-quarters of the patients studied used fewer than 15 opioid tablets. Three of the 62 patients needed opioid refills.

A lesson learned from this study about rhinoplasty suggests surgeons can start by prescribing 15 opioid pills, according to the study’s senior author Russell W. H. Kridel, M.D., a fellowship-trained facial plastic surgeon who practices in Houston, Texas, and past president of the American Academy of Facial Plastic and Reconstructive Surgery.

“If anybody is not managed by the 15 pills, it’s a good idea to see that patient to see why the patient’s pain requires more opioids,” Dr. Kridel says.

Additionally, it’s important for facial plastic and other surgeons to avoid over-prescribing opioids for reasons beyond the risk of patient abuse or addiction, according to Dr. Kridel.

Unused opioid pills often get into the wrong hands, he says. Dr. Kridel and coauthors cited a 2011 study by Maxwell JC in Drugs and Alcohol Review that found 71% of opioid abusers receive the drugs through methods of diversion and 55% of those get pills via friends or family members who were prescribed the drugs and have leftover pills.

It’s incumbent upon physicians to reduce excess pills by prescribing fewer opioids and recommending that patients dispose of any leftover pills properly or store them in a locked medicine cabinet. Proper disposal includes taking the pills to pharmacies, police stations or other credible locations that accept them.

Surgeons should also talk with their rhinoplasty patients before surgery to learn patients’ pain tolerance and opioid use in previous surgeries, to better determine how many opioids a person might need. The surgeon should educate patients that it’s important that they taper off of opioids and start acetaminophen as soon as possible to prevent abuse or addiction.

“We prefer acetaminophen to ibuprofen, which has the potential to increase bleeding,” Dr. Kridel points out.

Surgeons can and should verify patient opioid use histories by accessing individual state Prescription drug monitoring programs, according to Dr. Kridel.

“The point of our paper is that we shouldn’t just pick a figure and prescribe that,” Dr. Kridel says. “I think every doctor who does a certain procedure can do a study that looks at how many pills that doctor prescribes and asks 20 patients or so how many they used. If it turns out that they’re using less than prescribed, surgeons can start with the lower number.”

Dr. Kridel says he has since changed opioid prescribing after other surgeries, including the facelift.

“We were ordering more opioids for facelift patients and discovered they don’t need as many, either. Facelift patients feel pressure and tightness more than they feel pain,” he says.

The CDC reports that prescription and illicit opioids are the main driver of drug overdose deaths today, with 42,249 people dying from these drugs in 2016.


1. Sethi RKV, Lee LN, Quatela OE, Richburg KG, Shaye DA. Opioid Prescription Patterns After Rhinoplasty. JAMA Facial Plast Surg. Published online September 06, 2018. doi:10.1001/jamafacial.2018.0999.

2. 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