EMMA BOYAJIEFF, BS
Drexel University College of Medicine
SUMMARY POINTS
A large number of plastic surgery procedures are performed each year with a projected rise in coming years.
On average, plastic surgeons prescribe double the number of opioids than are consumed by their patients postoperatively.
Procedure specific guidelines are needed on postoperative opioid prescribing for plastic surgeons.
Multiple strategies exist to encourage safer opioid prescribing in plastic surgery, such as patient education and multimodal pain management. Further research on these strategies is necessary to encourage plastic surgeons to implement them in their practice.
ANALYSIS
Background
The prevalence of plastic and reconstructive surgery procedures continues to increase, with 2.3 million cosmetic surgical procedures and 6.8 million reconstructive procedures performed in 2020 by surgeons from the American Society of Plastic Surgeons (ASPS) in the U.S. (1). Specific reports are not yet available for more recent years, but 2020 saw a drop in cosmetic procedures during the Covid-19 pandemic. Global reports released from the International Society of Aesthetic Plastic Surgery showed a 19.3% increase in overall procedures performed by plastic surgeons worldwide in 2021 (2). The 3 most common cosmetic surgical procedures performed by ASPS plastic surgeons in 2020 were rhinoplasty, blepharoplasty, and rhytidectomy, while the 3 most common reconstructive procedures were tumor resection, laceration repair, and scar revision (1).
With the large number of plastic surgery procedures being performed, post-operative pain management for these procedures affects an increasing number of patients. The prescribing of opioids to patients post-operatively is of interest as the U.S. is in the midst of an Opioid epidemic. National opioid overdose deaths in 2021 reached 80,411, with 16,706 directly involving prescription opioids (3). Of overdoses involving prescription opioids, the most common drugs were methadone, oxycodone, and hydrocodone (4). Even in overdose deaths not arising from direct use of prescription opioids, prescription pills are often still involved. In opioid-naive patients, acute postoperative pain management is the most common cause of new opioid prescriptions, and approximately 3% of these patients continue to use opioids for more than 90 days postoperatively (5,6). Diversion is also of concern, with a significant amount of opioids used illicitly coming from extra prescription pills of friends and family of the user (7). Only 1% of patients undergoing plastic surgery procedures were found to have disposed of their extra opioids properly 3 months post procedure, allowing the potential for drug diversion of their extra pills (8). These issues signify the importance of responsible opioid prescribing by physicians. The increasing number of plastic and reconstructive surgery procedures in the U.S. raises the question of how plastic surgeons are prescribing opioids to their patients post-operatively.
Figure 1: How plastic surgery patients dispose of excess opioids. SEE ARTICLE from the Journal of the American Society of Plastic Surgeons (8)
Analysis
One way to encourage responsible opioid prescribing by physicians and decrease risk to patients is to analyze opioid prescribing patterns within different specialties. Within plastic surgery, multiple studies have been performed to report on postoperative opioid prescribing. In 2020, a questionnaire of 170 patients undergoing outpatient plastic surgery procedures showed these patients were prescribed an average of 26 pills yet consumed only 13 (9). The most opioids were consumed by patients undergoing reduction mammaplasty and abdominoplasty, with an average of 17 and 18.6 pills consumed (9). Also in 2020, data from the Nova Scotia Provincial Monitoring Program (NSPMP) demonstrated an average of 36.1 opioids prescribed for hand procedures and 31.9 for breast procedures, suggesting opioid overprescribing occurs for plastic surgery procedures outside of the U.S. all well (10).
A large retrospective review of 479 patients from 2018-2019 showed similar postoperative consumption in breast surgery patients, with an average of 7.2-14.6 pills consumed per patient depending on the surgery type (8). Abdominoplasty patients consumed an average of 14.9 pills. Looking at procedure specific prescribing trends, most categories showed an excess of pills prescribed compared to those consumed (8). Immediate implant based reconstruction was the greatest contributor to excess opioids with 479 patients prescribed 5895 total pills, 1528 of which were excess (8). Again in 2022 patients were shown to consume only half of their prescribed opioids, with an average of 28 opioid pills prescribed and 13.8 consumed in 266 patients undergoing outpatient plastic surgery (11).
Figure 2: A sample of 444 patients showing excess opioid pill counts by plastic or reconstructive surgery procedure type. SEE ARTICLE from the American Society of Plastic Surgeons (10)
Enhanced recovery after surgery (ERAS) protocols may be effective at reducing opioid prescribing following plastic surgery procedures. Comparing pre-ERAS to post-ERAS implementation showed a 34% reduction in morphine equivalents prescribed postoperatively by a single plastic surgeon in Massachusetts (12). A retrospective review of 136 patients undergoing outpatient breast surgery showed a 41.5% decrease in morphine equivalents prescribed after the implementation of a ERAS protocol emphasizing patient education, multimodal pain management, and intraoperative blocks (13). More research is needed to determine how ERAS protocols may affect opioid prescribing trends in plastic surgery with different physicians and within different procedure types.
Discussion
The United States continues to suffer through an opioid epidemic, resulting in greater healthcare utilization and costs and increased mortality and morbidity for patients (14). With a significant portion of opioids used coming from physician prescriptions and an increasing prevalence of plastic surgery procedures, understanding trends in opioid prescribing following plastic surgery procedures can help identify the source of opioids and serves as a potential opportunity for decreasing opioid exposure in patients. Multiple studies show that as many as half of opioids prescribed postoperatively by plastic surgeons are not consumed, which identifies a potential for drug diversion. In opioid naive patients, special care must be taken in opioid prescribing to avoid opportunity for the development of substance-use disorders. The over-prescription of opioids in plastic surgery demonstrates the need for procedure specific guidelines for outpatient opioid prescribing for plastic surgeons. More research is needed to establish specific guidelines. In addition, protocols for multimodal pain management and patient education including the disposal of unused pills may help establish safer opioid use in plastic surgery.
REFERENCES
American Society of Plastic Surgeons. Plastic Surgery Statistics Report: ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. https://www.plasticsurgery.org/documents/News/Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf. Published 2021. Accessed June 28, 2023.
The International Society of Aesthetic Plastic Surgery. ISAPS International Survey on Aesthetic/Cosmetic Procedures Performed in 2021. https://www.isaps.org/media/vdpdanke/isaps-global-survey_2021.pdf. Published 2022. Accessed June 28, 2023.
National Institute on Drug Abuse. Drug Overdose Death Rates. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=Opioid%2Dinvolved%20overdose%20deaths%20rose,with%2080%2C411%20reported%20overdose%20deaths. Published February 9, 2023. Accessed June 28, 2023.
Ossiander EM. Using textual cause-of-death data to study drug poisoning deaths. Am J Epidemiol. 2014;179(7):884-894. doi:10.1093/aje/kwt333
Waljee JF, Li L, Brummett CM, Englesbe MJ. Iatrogenic Opioid Dependence in the United States: Are Surgeons the Gatekeepers?. Ann Surg. 2017;265(4):728-730. doi:10.1097/SLA.0000000000001904
Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. BMJ. 2014; 348 g1251. doi: 10.1136/bmj.g1251.
Inciardi JA, Surratt HL, Cicero TJ, Kurtz SP, Martin SS, Parrino MW. The "black box" of prescription drug diversion [published correction appears in J Addict Dis. 2013;32(3):323]. J Addict Dis. 2009;28(4):332-347. doi:10.1080/10550880903182986
Chu JJ, Janis JE, Skoracki R, Barker JC. Opioid Overprescribing and Procedure-Specific Opioid Consumption Patterns for Plastic and Reconstructive Surgery Patients. Plast Reconstr Surg. 2021;147(4):669e-679e. doi:10.1097/PRS.0000000000007782
Rose KR, Christie BM, Block LM, Rao, Venkat KM, Michelotti, BF. Opioid Prescribing and Consumption Patterns following Outpatient Plastic Surgery Procedures. Plastic and Reconstructive Surgery. 2019;143(3):p 929-938. doi:10.1097/PRS.0000000000005351
Boudreau CG, Samargandi O, McGuire C, MacIssac K, Helmi A, Tang D. Opioid Prescribing and Use Following Common Plastic Surgery Procedures. Plast Reconstr Surg Glob Open. 2020;8(9 Suppl):154-154. Published 2020 Oct 9. doi:10.1097/01.GOX.0000721128.52245.6e
Zorrilla AM, Sanchez-Covarrubias AP, Martin K, Rodriguez M. Pain Management and Opioid Consumption After Outpatient Cosmetic Surgery. The American Journal of Cosmetic Surgery. 2022;0(0). doi:10.1177/07488068221116529
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:p 22-28. doi:10.1016/j.jpra.2021.10.006
Wong S, Lombana NF, Falola RA, Park P, Saint-Cyr MH. Decreasing Opioids in Outpatient Breast Surgery with an Enhanced Recovery after Surgery Program and Preoperative Education. Plastic and Reconstructive Surgery. 2023;151(5):p 941-947. doi: 10.1097/PRS.000000000001006
Ronan MV, Herzig SJ. Hospitalizations Related To Opioid Abuse/Dependence And Associated Serious Infections Increased Sharply, 2002-12. Health Aff (Millwood). 2016;35(5):832-837. doi:10.1377/hlthaff.2015.1424
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