NEW ORLEANS -- A brief but intense opioid protocol for post-tonsillectomy pain did not lead to opioid dependence within the first year after surgery, a retrospective analysis of active-duty military personnel showed.
Of almost 700 patients who received as much as a 15-day postoperative prescription of opioid-containing medication, none had a referral for treatment of opioid dependence over the next 12 months. On average, the patients received almost twice as many opioid tablets for post-tonsillectomy pain relief as otolaryngologists reported in a recent survey, and almost 40% of the patients received refills within 30 days of surgery.
Despite involving a patient population within a closed healthcare system with worldwide electronic health record (EHR) connectivity, the study demonstrated the feasibility and safety of a short-term, high-quantity opioid protocol for adults undergoing tonsillectomy, reported Christopher J. Hill, MD, of the Naval Medical Center-Portsmouth, Virginia, at the American Academy of Otolaryngology-Head and Neck Surgery Foundation meeting.
"We report the highest-powered study to date assessing opioid prescriptions following adult tonsillectomy," Hill said. "At our institution, 93% of patients received between a 5- and 15-day course of opioids, depending on the frequency of administration, and 38% of patients received at least one refill within 30 days postoperatively. We found no referrals for opioid abuse or dependence in the year following surgery."
"With these data, we are not unequivocally endorsing a liberal dispensation of opioids following tonsillectomy, as there are still well demonstrated risks of chronic opioid abuse," he stated. "However, we believe that these findings are in line with previous studies demonstrating that the judicious use of short-term narcotic pain medication to appropriately manage pain in post-tonsillectomy patients can be done safely."
The clinical setting of adult tonsillectomy potentially has the makings of a setup for chronic opioid use. The procedure is associated with severe postoperative pain that can persist for 10 to 14 days and often requires opioid medication for adequate pain control, Hill noted.
A recent retrospective review of a large medical claims database showed a 0.6% incidence of opioid abuse in postoperative patients with no history of opiate use. The risk of abuse correlated significantly with duration of opioid use and number of refills. A retrospective cohort study from Canada showed a 44% increase in the risk of long-term opioid use when a patient received an opioid prescription within 7 days of outpatient surgery.
A recent survey of otolaryngologists examined opioid prescribing practices for common ear-nose-throat (ENT) procedures. Adult tonsillectomy was associated with the highest number of opioid doses, averaging 37 tablets following surgery.
With that background information, Hill and colleagues conducted a retrospective review of EHRs for active-duty military personnel who underwent tonsillectomies at the Portsmouth medical center from 2012 to mid-2018. Primary objectives were to understand the incidence and risk factors for post-tonsillectomy opioid abuse, recognize that large quantities of opioids are often prescribed for adult tonsillectomies, and to show that appropriate management of post-tonsillectomy pain in adults does not increase the risk of long-term opioid misuse.
Data collection included demographics, postoperative narcotic prescriptions and refills within 30 days and 1 year, and referrals for substance-abuse rehabilitation. They excluded patients who underwent other procedures at the same time.
Data analysis comprised 666 patients who had a mean age of 26, and women accounted for 51% of the study population. The most commonly prescribed opioid regimen was 60 tablets of 5 mg/325 mg of oxycodone/acetaminophen, a 5- to 7-day supply depending on dosing frequency. Hill said 93% of patients received at least 60 tablets, and the average was 70 tablets. Subsequently, 38% of the patients had at least one refill within 30 days.
A fourth of the patients received additional prescriptions for narcotics within 1 year for a variety of indications, most often musculoskeletal pain and postoperative pain. Medical records showed that 19 patients had referrals for substance abuse within 1 year of tonsillectomy: 17 for alcohol abuse and one each for marijuana and a combination of marijuana and alcohol abuse. None of the referrals involved opioid abuse or dependence.
"It's worth emphasizing that the military health system is an all-inclusive and closed system, meaning that referrals for substance abuse anywhere in the world can be viewed through our [EHR] system," said Hill. "Additionally, active-duty service members are subject to random urinalysis. While that may act as a deterrent to substance abuse, it's unlikely that we would have missed an individual who developed opioid dependence."
In response to a question, Hill said the otolaryngology staff agreed on the 60-tablet prescription as a first step toward less reliance on opioids for postoperative pain relief. Some otolaryngologists have already begun transitioning to ibuprofen and acetaminophen as first-line pain relief after tonsillectomy, reserving opioids for breakthrough pain.
Though conducted within the military health system, the limited-duration opioid protocol is "absolutely applicable" to otolaryngology practices outside the military, said Mark K. Wax, MD, of Oregon Health & Science University in Portland. Clinical practices could not replicate the record-keeping capacity of the military health system, but the opioid protocol definitely could be implemented, he told MedPage Today.
Hill and co-authors disclosed no relevant relationships with industry.