CSA Online First

CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Rita Agarwal, MD, FAAP, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

"Better solutions to difficult problems are usually made when all sides are heard."

Steven Goldfien, MD

 

Opioids, Pain and Surgery

by
  • Agarwal, Rita, MD, FAAP, FASA
| Sep 10, 2019

6 in 10 Kids Got Opioids After Tonsil Surgery, Study Says

So screams the headline from The Daily Beast

Agarwal-Rita“In the midst of the opioid crisis, doctors sent many kids home with oxycodone and hydrocodone” it goes on to say. Another example of scaremongering and sensational headlines, or is this something we should still be concerned about?

Well according to the actual article, there was no greater risks of complications in the patients who received opioids versus those who did not. The study analyzes  a large cohort of children from a private insurance data base who underwent tonsillectomy and adenoidectomy (T&A) procedures. They reviewed opioid prescriptions filled or refilled and incidence of admission within seven days. In this retrospective review of over 15,000 patients there was no increased complication rate as measured by the authors. There was no way to determine pain, nausea, vomiting, or any other measure of postoperative well-being.  Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children. Chua KP, Harbaugh CM, Brummett CM, Bohm LA, Cooper KA, Thatcher AL, Brenner MJ. JAMA Otolaryngol Head Neck Surg. 2019 Aug 8. doi: 10.1001/jamaoto.2019.2107

The Daily Beast article goes on to ask, “what about ice cream?” While the traditional post tonsillectomy treatment of ice cream is great for some patients, it is definitely not for all. A tonsillectomy procedure is an extremely painful surgery, although certain techniques (subtotal tonsillectomy, coblation or cryoanalgesia) can decrease postoperative pain and, while used by some surgeons for some patients (and I confess I do not understand the indications for one technique versus another), they are not being used for all. Local anesthetic injected into the tonsillar bed has had mixed results in the literature and is not commonly used.

Most Otolaryngologists now send patients home with around the clock acetaminophen and ibuprofen, with or without opioids. In one survey from Canada the surgery that most otolaryngologists prescribed opioids for was tonsillectomy/adenoidectomy, but there was a huge degree of variability: Opioid prescribing practices following elective surgery in Otolaryngology-Head & Neck Surgery.

Interestingly, until the FDA  issued black box warnings on the use of codeine and tramadol in children, most children were being sent home with a codeine solution after T&A. Around the same time there were increasing studies showing that hydrocodone was subject to some of the same metabolic differences as codeine and used similar hepatic pathways to produce the active ingredients. Discomfort with prescribing oxycodone and other oral opioids in children is one of the reasons that otolaryngologists put aside their fear of postoperative bleed and liberalized their use of ibuprofen and even ketorolac.

Numerous studies confirm the lack of consistency with opioid prescribing, which is a great area for further research, but calls for returning to no opioids are disingenuous and do a disservice to our patients. We must treat pain appropriately and we need to look for better analgesics, better techniques, and optimize non-pharmacologic techniques. I remember having my tonsils out as a child and I recall the absolute misery of several days of not being able to swallow, sleep, or read (my go-to distraction method). I also recall feeling snookered by all the adults who told me “you can have as much ice-cream as you want after the surgery.” Ummm no, I wasn’t able to eat any ice-cream until a week later.  All I wanted was ice.

Opioid prescriptions have been steadily decreasing over the past two years and the number of opioid related overdose deaths are decreasing as well. While opioid use disorder and addiction are real problems, inadequate pain management should not be ignored. The push for opioid free anesthesia and surgery is laudable but shouldn’t replace common sense and careful review of the literature. We as anesthesiologists and pain specialists can and should help our surgical colleagues find the correct balance.

 

 

 

 

 

 

 


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