Design
All elective adult tonsillectomies performed by a single surgeon
(BLINDED FOR REVIEW) at a single institution between June 2, 2017 and
September 20, 2019 were reviewed. During this time, the surgeon
instituted a change in postoperative pain management for quality
improvement purposes. Prior to the change, patients were prescribed an
opioid analgesic and maximum safe dose of acetaminophen postoperatively
and counseled against using ibuprofen (Group 1). After the change,
patients were prescribed maximum safe doses of acetaminophen and
ibuprofen and counseled by the surgeon about the risks of opioid
analgesics (Group 2). For patients in Group 2, opioids were only
prescribed as postoperative rescue medications, if NSAID was
contraindicated due to an allergy or medical condition, or if
specifically requested by the patient preoperatively after receiving
counseling on opioid risks and the benefits of an NSAID-based regimen.
No patient in either group was denied a prescription for opioid
medications if they specifically requested them preoperatively, or if
they felt their pain was not adequately controlled postoperatively. All
tonsillectomies were performed using a “cold” technique without
electrocautery or Coblation. Exclusion criteria included pediatric
patients less than 18 years of age at the time of surgery, patients
undergoing tonsillectomy for malignancy, and patients undergoing
additional procedures such as uvulopalatopharyngoplasty or
adenoidectomy.
The primary intervention in this study was the postoperative
prescriptions for ibuprofen and acetaminophen. The secondary
intervention was counseling regarding the risks of opioid analgesics and
the benefits of a non-opioid pain regimen. Additional information
collected via chart review included patient demographic information,
comorbidities as defined by the patient’s American Society of
Anesthesiologists (ASA) Physical Status Score, procedure information,
pathology results, relevant patient history related to substance abuse,
opioid misuse, chronic pain, or anxiety/depression, any medical
contraindications to ibuprofen or acetaminophen, any reported adverse
effects from pain medications, and any complications related to the
surgical procedure.
Information regarding filled perioperative opioid prescriptions as well
as dose and duration was extracted from the PMP website. A waiver was
provided by the BLINDED FOR REVIEW Board of Pharmacy to permit use of
de-identified information from the PMP website for the purposes of this
research study. The website was searched for the patient’s identifying
information including any known previous names or aliases, and any
prescription of any controlled substance tracked by the PMP was recorded
for a time period ranging from one month prior to the surgical date to
three months after the surgical date. The PMP database was searched for
patient records for all states and non-state medical systems
participating in the online database (33 of 50 US states, as well as the
US Military Health System and Puerto Rico).
Simple student t-tests of two proportions for binary data or
nonparametric Mann-Whitney U tests for continuous data were used to
compare the primary outcomes and other relevant characteristics between
Groups 1 and 2. A subgroup analysis was performed on Group 2 to compare
relevant patient factors between those who received ibuprofen and filled
an opioid prescription and those who received ibuprofen and did not fill
an opioid prescription, though the study was not properly powered to
detect a difference in this subgroup. A nonparametric Mann-Whitney U
test was used to compare the average initial prescribed opioid dose
between groups, as these were not normally distributed. Finally, a
multiple logistic regression was designed to evaluate the independent
effect of an ibuprofen prescription and counseling on opioid
prescription filling while controlling for age, race, and a history of
opioid use, substance abuse, chronic pain, or anxiety/depression.