PracticeUpdate Dermatology February 2019

EDITOR’S PICKS 16

Opioid Prescribing for Acute Postoperative Pain After Cutaneous Surgery Journal of the American Academy of Dermatology Take-home message

of available evidence and the opinion of the authors. RESULTS Most patients undergoing cutaneous surgery do not require opioid analgesia. For those who do, the pain duration warranting opi- oid analgesia is generally less than 36 hours. Opioid refill requests warrant a follow-up visit to ascertain the cause of ongoing pain after exci- sional procedures. LIMITATIONS The recommendations are not based on prospective randomized trials. CONCLUSIONS The presented recommendations for opioid prescription practice are derived from available evidence, recommendations, and expert opinion. Opioid Prescribing for Acute Postoperative Pain After Cutaneous Surgery. J Am Acad Derma- tol 2018 Oct 01;[EPub Ahead of Print], JJ Lopez, NS Warner, CJ Arpey, et al. www.practiceupdate.com/c/74499

• In this article, the authors reviewed the current literature on opioid prescription for postoperative pain after cutaneous surgery. Acute pain after cutaneous surgery was usually deemed minor, and patients did not require an opioid. For patients who did require an opioid, severe pain duration was generally less than 36 hours. • While over-prescription of opioids has been observed after surgical procedures, this literature review suggests that most patients do not require opioid analgesics after cutaneous surgery. When an opioid pain relief is warranted, it should be limited to 36 hours. Refill requests warrant a follow-up visit to investigate the cause of ongoing pain. InYoung Kim MD, PhD

Abstract BACKGROUND Little information is available to predict which patients require opioid analge- sia following cutaneous surgery. When opioids are indicated, information is lacking regarding the optimal opioid agent selection and dosage.

OBJECTIVE To make recommendations for opioid prescription after cutaneous surgery. METHODS A PubMed literature search was conducted to review the available literature. Recommendations are presented on the basis

COMMENT By David G. Brodland MD T his literature review nicely collates the available information on postoperative pain. Whether it is cryosurgery or excision, cosmetic or oncologic surgery, we do procedures daily that cause pain in our patients. That is why we should be well-versed on the subject, particularly in this age of the opioid crisis. The article summarizes what is known while exposing a knowl- edge gap that requires continued study. The valuable message can be capsulized as follows: • Doctors are the source of illicit opioid use 71% of the time! • When we prescribe narcotics, we usually prescribe too much… sometimes way too much! • Most of our surgical patients don’t need opioids. • Average pain levels after excision and closure is a 2 out of 10 (10 being severe pain). • Those who take narcotics use a mean of 3.7 pills; 79% use fewer than 5 pills. • Anxiety about the expected level of pain correlates with increased pain postoperatively. • Characteristics associated with a greater than average amount of pain include: wounds on the lip, nose, periocular area, gen- italia, and forehead/scalp; female gender; flaps and grafts; interpolation flaps; age <66 years; more stages of excision; and perioperative anxiety about pain. • When refill of a narcotic is requested, consider in-office eval- uation for an infection or other complication. Overall conclusions: • Instruct patients to use acetaminophen and/or ibuprofen… opioids if pain is expected to be greater than normal.

• Opioids are usually not necessary. • The number of opioid pills, taken as prescribed, should last no more than 36 hours. • Follow-up is indicated when a refill is requested to assess the cause of ongoing pain. My two cents based on our studies (references 8 and 12) and my experience: • Manage anxiety…inform your patients what to expect (pain duration, peak, and intensity). • Peak pain occurs 2 to 6 hours postop and diminishes toward baseline by 12 hours…tell them! • Then, if at risk for greater pain, ask them if they want a nar- cotic…often with information, they’ll decline. • Postoperative pain is acute, so use analgesics with faster onset rather than slow…ibuprofen and acetaminophen (onset 24 and 45 minutes, peak effect 1 to 2 hours and 2to 4 hours, respectively) rather than naproxen. Naproxen is slow onset but longer lasting (onset 1 hour and peak at 5 hours), so it’s less ideal for acute pain. • My directions are to take either acetaminophen 1000 mg or ibuprofen 400 mg upon leaving the office and take the other (no sooner than 1 hour later) for “breakthrough pain.” Repeat as needed every 4 hours after the initial dose for 12 hours. • If patients declines a narcotic but you feel that they may need it that evening, offer to provide a written script that they can fill should they need it and discard the next day if not.

Dr. Brodland is a Dermatologic Surgeon at Zitelli & Brodland PC, Skin Cancer Center in Pittsburgh, Pennsylvania.

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