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Rothman Opioid Foundation
Oct 56 min read

Opioid Use and Alternatives for Pain Management in Plastic & Reconstructive Surgery

TAYLOR DILISI, MS

Philadelphia College of Osteopathic Medicine


SUMMARY POINTS 


  • Plastic surgery patients are overprescribed opioids, often only needing about half of the quantity prescribed to control their postoperative pain.


  • The side effects and potential for misuse, dependence, and diversion of opioids make alternative pain management methods preferred by both surgeon prescribers and patients. 


  • Alternative treatments for pain, including multimodal analgesia protocols, enhanced recovery after surgery (ERAS) protocols, and long-acting nerve blockades, have successfully treated post-operative pain in the absence or limited use of opioids.


ANALYSIS 


Background 


The opioid crisis continues to impact the United States, with 74.8% of approximately 92,000 overdose deaths in 2020 involving opioid use (1). Surgeons are responsible for nearly 37% of all opioid prescriptions and have been found to overprescribe opioids in the perioperative period (2). In plastic surgery, overprescribing of opioids is a known problem, with patients consuming, on average, only half of their prescribed pill quantity (13). A 2020 study found that plastic surgery patients are left with an average excess of 13 pills from their prescriptions, consequently leading to the potential for pill diversion and misuse (13). Up to 6.5% of opioid-naive surgical patients develop persistent opioid use postoperatively, making opioid misuse one of the most common complications of elective surgery (3). Uncontrolled pain may lead to chronic pain and further opiate dependence. (10) The elective nature of most plastic surgery procedures highlights the importance of patient satisfaction and the need for adequate pain control. Studies have found that patients are indifferent to pain management modalities, and less than 1/3 of patients expect to be prescribed opioids postoperatively (3). 45% of patients also favor a non-opioid alternative to manage postoperative pain (3). Alternative approaches to pain management are gaining popularity as preferred alternatives due to the absence of potential for opioid dependence/withdrawal and side effects, including respiratory depression, sedation, and constipation (14). 


Analysis 


Multimodal approaches to pain management in the absence or limited use of opioids are favored by surgeons and patients alike (9). They have been shown to decrease recovery time and postoperative complications (10). Multimodal analgesia treats pain by administering a combination of non-opioid alternatives with different mechanisms of action, such as a  combination of local or regional analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, and adjuvants such as dexamethasone or gabapentin (10). Patients begin multimodal analgesia regimens pre-operatively. Under this protocol, patients should receive NSAIDs and COX-2 inhibitors as scheduled doses rather than as needed in this protocol (9). 




Figure 1. Example of a Multimodal Analgesic Protocol for Abdominal Wall Reconstruction SEE ARTICLE from Barker JC, DiBartola K, Wee C, et al. Preoperative multimodal analgesia decreases postanesthesia care unit narcotic use and pain scores in outpatient breast surgery. Plastic and Reconstructive Surgery. 2018;142(4). doi:10.1097/prs.0000000000004804



Multimodal analgesia for postoperative head and neck free flap reconstruction reduced postoperative narcotic use and improved pain scores (4). Preoperative multimodal analgesia of acetaminophen, gabapentin, and celecoxib significantly reduced postoperative narcotic use in outpatient breast surgery patients compared to breast surgery patients that received no preoperative analgesia and intraoperative IV acetaminophen (19). Pain scores were also reduced in the multimodal analgesia groups. A major benefit of multimodal analgesia is the ability to tailor regimens to each patient's specific needs, making it ideal for patients with contraindications. 


Enhanced recovery after surgery (ERAS) protocols incorporating perioperative education and pain control strategies have allowed for a 3-fold decrease in overall opioid prescriptions when employed with regional blocks in outpatient care settings (5). Implementing an ERAS protocol for elective plastic surgery by a single surgeon resulted in a statistically significant decrease in postoperative pain and opiate prescription quantities (6,11). Patients received a single preoperative dose of oral acetaminophen and gabapentin, and postoperative oral acetaminophen for 24 hours followed by as-needed, low-dose twice-daily gabapentin for 7–14 days, ibuprofen as needed, and oxycodone when necessary (6). Comparison of the pre to post-ERAS intervals revealed a 29.3% reduction in the mean daily morphine milligram equivalents (MME) per patient, a 64.5% reduction in the mean opiate prescription duration, and a 58.1% reduction in the number of opiates prescribed (6). Similar opioid-restrictive protocols have decreased the number of opioid prescriptions by 20% after outpatient procedures without an increase in refill rates (7). 


Using local and regional anesthetic blockades of liposomal bupivacaine and ropivacaine in conjunction with opioid-restrictive protocols has also successfully reduced postoperative opioid use and pain (8,12). Catheter-based infusion of local anesthetic in plastic surgery procedures resulted in an opioid-sparing effect in 92% of studies reviewed (9). Another review found that all evaluated studies that reported opioid consumption demonstrated a statistically significant decrease when patients were administered paravertebral, intercostal, and pectoralis nerve blocks in breast and flap reconstruction. Postoperative pain was also significantly reduced in patients that received paravertebral blocks (8). The use of local and regional anesthetics is favorable due to the local effects, minimal central penetration, and long duration of action for pain control.


Discussion


Pain management in plastic and reconstructive surgery through opioid-alternative methods such as NSAIDs, acetaminophen, neuropathic pain medications, and local anesthetic nerve blocks are feasible for treating postoperative pain alone or with limited opioid use (5,10). Additional long-term, repeated studies are necessary to confirm the efficacy of multimodal opioid-alternative protocols and evaluate patient satisfaction. Multimodal and ERAS protocols should continue to be patient-specific and modified for high-risk patients with preexisting conditions.




REFERENCES: 

  1. Death Rate Maps & Graphs. Centers for Disease Control and Prevention. June 2, 2022 Accessed June 21, 2023. https://www.cdc.gov/drugoverdose/deaths/index.html#:~:text=Opioids%20were%20involved%20in%2068%2C630,and%20without%20synthetic%20opioid%20involvement.

  2. Rose KR, Christie BM, Block LM, Rao VK, Michelotti BF. Opioid Prescribing and Consumption Patterns following Outpatient Plastic Surgery Procedures. Plast Reconstr Surg. 2019;143(3):929-938. doi:10.1097/PRS.0000000000005351

  3. Long EA, Johnson SP, Valmadrid A, Wormer BA, Drolet BC, Perdikis G. Plastic surgery patient expectations for postoperative opioid prescriptions. Annals of Plastic Surgery. 2020;84(6S). doi:10.1097/sap.0000000000002268 

  4. Eggerstedt M, Stenson KM, Ramirez EA, et al. Association of perioperative opioid-sparing multimodal analgesia with narcotic use and pain control after head and neck free flap reconstruction. JAMA Facial Plastic Surgery. 2019;21(5):446-451. doi:10.1001/jamafacial.2019.0612

  5. Straughan DM, Lindsey JT, McCarthy M, Legendre D, Lindsey JT. Enhanced recovery after surgery protocol with ultrasound-guided regional blocks in outpatient plastic surgery patients leads to decreased opioid prescriptions and consumption. Aesthetic Surgery Journal. 2021;41(8). doi:10.1093/asj/sjab137

  6. Faulkner HR, Coopey SB, Sisodia R, Kelly BN, Maurer LR, Ellis D. Does an eras protocol reduce postoperative opiate prescribing in plastic surgery? JPRAS Open. 2022;31:22-28. doi:10.1016/j.jpra.2021.10.006

  7. Johnson SP, Wormer BA, Silvestrini R, Perdikis G, Drolet BC. Reducing opioid prescribing after ambulatory plastic surgery with an opioid-restrictive pain protocol. Annals of Plastic Surgery. 2020;84(6S). doi:10.1097/sap.0000000000002272

  8. Abi-Rafeh J, Safran T, Abi-Jaoude J, Kazan R, Alabdulkarim A, Davison PG. Nerve blocks in breast plastic surgery: Outcomes, Complications, and comparative efficacy. Plastic & Reconstructive Surgery. 2022;150(1). doi:10.1097/prs.0000000000009253 

  9. Barker JC, Joshi GP, Janis JE. Basics and best practices of multimodal pain management for the plastic surgeon. Plastic and Reconstructive Surgery - Global Open. 2020;Publish Ahead of Print. doi:10.1097/gox.0000000000002833 

  10. Schoenbrunner AR, Joshi GP, Janis JE. Multimodal analgesia in the aesthetic plastic surgery: Concepts and strategies. Plastic and Reconstructive Surgery - Global Open. 2022;10(5). doi:10.1097/gox.0000000000004310

  11. Echeverria-Villalobos M, Stoicea N, Todeschini AB, et al. Enhanced recovery after surgery (ERAS). The Clinical Journal of Pain. 2019;36(3):219-226. doi:10.1097/ajp.0000000000000792 

  12. Ilfeld BM, Eisenach JC, Gabriel RA. Clinical effectiveness of liposomal bupivacaine administered by infiltration or peripheral nerve block to treat postoperative pain. Anesthesiology. 2020;134(2):283-344. doi:10.1097/aln.0000000000003630 

  13. Chu JJ, Janis JE, Skoracki R, Barker JC. Opioid overprescribing and procedure-specific opioid consumption patterns for plastic and reconstructive surgery patients. Plastic & Reconstructive Surgery. 2021;147(4). doi:10.1097/prs.0000000000007782

  14. Machelska H, Celik M. Advances in achieving opioid analgesia without side effects. Frontiers in Pharmacology. 2018;9. doi:10.3389/fphar.2018.01388

  15. Bartlett EL, Zavlin D, Friedman JD, Abdollahi A, Rappaport NH. Enhanced recovery after surgery: The Plastic Surgery Paradigm Shift. Aesthetic Surgery Journal. 2017;38(6):676-685. doi:10.1093/asj/sjx217 

  16.  Bernstein JL, Schlechtweg KA, Nwigwe V, Fullerton N, Imahiyerobo TA. Pediatric pain and pain management after ambulatory plastic surgery. Annals of Plastic Surgery. 2022;88(3). doi:10.1097/sap.0000000000003143 

  17.  Donohoe GC, Zhang B, Mensinger JL, Litman RS. Trends in postoperative opioid prescribing in outpatient pediatric surgery. Pain Medicine. 2019;20(9):1789-1795. doi:10.1093/pm/pny284 

  18. Sherif RD, Lisiecki J, Waljee J, Gilman RH. Opioid prescribing habits and pain management among aesthetic plastic surgeons. Aesthetic Plastic Surgery. 2021;46(2):965-971. doi:10.1007/s00266-021-02494-y

  19. Barker JC, DiBartola K, Wee C, et al. Preoperative multimodal analgesia decreases postanesthesia care unit narcotic use and pain scores in outpatient breast surgery. Plastic and Reconstructive Surgery. 2018;142(4). doi:10.1097/prs.0000000000004804

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