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ATLANTA -- Patients who undergo nasal surgery are probably being prescribed more opioid analgesics than they need, researchers found.

In over 200 surveyed sinonasal surgery patients, 90% took 15 or fewer opiate tablets from the day of surgery to 3 days postop, reported Seerat Poonia, MD, of the University of Pennsylvania, Philadelphia.

All patients in the study were prescribed between 15 and 30 tablets of oxycodone 5 mg and acetaminophen 325 mg, leaving a large number of unused tablets with the potential for misuse or diversion, according to the study, presented here at the 2018 meeting of the American Academy of Otolaryngology-Head and Neck Society Foundation (AAO-HNSF).

"In routine sinonasal surgery, 15 oxycodone tablets provided sufficient pain control for 90% of our patients, and thus postoperative opiate prescriptions may be of larger quantity than necessary," she said.

Since 1999, opioid prescriptions per person in the U.S. have tripled. Surgeons prescribe 37% of the opioids among the medical community. "A postop patient that's prescribed opiates is 44% more likely to become a long-term user than one that isn't," said Poonia.

"We also know that 80%, in general, of opioid abusers are not the original prescription recipient," she continued. "So in looking at a way for surgeons to have a palpable effect on this epidemic, it makes sense that decreasing the initial amount dispensed is a good place to start, not only to lessen the risk that patients transition to chronic use or misuse, but also to reduce the supply of unused and potentially diverted opiates."

Her group conducted the real-time survey in 219 patients treated at four academic medical centers and one private practice institution from the day of surgery to postoperative day 3, asking patients' each day about their postoperative pain and use of prescribed pain medication.

Patients were instructed to take acetaminophen every 6 hours as needed for pain and oxycodone for any pain that wasn't controlled by acetaminophen alone. The survey response was 100% for all postoperative days. Active smokers constituted 15.5% of the study group.

A total of 196 patients (89.5%) took 15 or fewer opiate tablets over the 4 days, and 51 (23.2%) took no opioid pain medication at all. No patient required a refill of his or her opioid prescription.

In examining opioid use over time, no significant change in opioid use was observed on either postoperative day 1 (P=0.62) or day 2 (P=0.08) compared with the day of surgery. The number of opioids used on postoperative day 3 decreased significantly relative to the day of surgery (P<0.001), reported Poonia.

The mean postoperative pain score was 3.83 on a visual analog scale (VAS) of 0 to 10, and VAS scores decreased significantly on each subsequent day following surgery:

• 0.67 decrease from the day of surgery to postop day 1 (P=0.01)
• 1.14 decrease from postop day 1 to postop day 2 (P<0.001)
• 1.73 decrease from postop day 2 to postop day 3 (P<0.001)

Mean VAS scores also declined over time:

• 4.71 on the day of surgery
• 4.04 on postop day 1
• 3.57 on postop day 2
• 2.98 on postop day 3

On multivariate analysis, active smoking was the only significant variable (P=0.023) that affected VAS scores and opiate use. Active smokers used 1.3 times as many opiates compared with nonsmokers (P<0.001).

There was a weakly positive but statistically significant correlation between opioid use and mean pain scores.

Poonia said that future needs include the development of evidence-based postoperative pain management guidelines following sinonasal surgery and the implementation of appropriate pain management patient education.