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Opioid workgroup guidelines address treatment of dermatologic postop pain

The Opioid-Prescribing in Dermatology Workgroup determined that 10% of patients or less undergoing 87 common dermatological procedures require postoperative opioid management at discharge.

“The challenge faced by dermatologic surgeons in these settings is to anticipate the degree of postoperative discomfort and attempt to select the analgesic with the most appropriate balance between analgesic properties and side effects,” Justin M. McLawhorn, MD, a dermatologist at the University of Oklahoma Health Sciences Center, and colleagues wrote. “This undertaking has been previously achieved with heavy reliance on clinical gestalt, provider intuition, convenience or traditional dogma, without much consideration of specific recommendations that are procedure-based.”

Forty members of the American College of Mohs Surgery, American Academy of Dermatology and American Vein and Lymphatic Society participated in the workgroup. All had board certification in dermatology and an active DEA license.

Researchers performed a literature review to identify current recommendations for dermatologic surgery postoperative pain management.

In all procedural scenarios, the panelists met consensus that non-opioid analgesics were appropriate for first-line postoperative pain management, unless contraindicated. Further, they determined that a minimum opioid pill count of zero is appropriate when only non-opioid analgesics would be required to manage postoperative pain.

When non-opioid management is recommended, patients need instructions on scheduling over-the-counter medications to provide adequate relief, with 1 g of acetaminophen every 8 hours and/or 400 mg ibuprofen every 4 hours. However, when opioids are “reasonably needed for adequate analgesia,” the panelists agreed that acetaminophen and/or nonsteroidal medications should be used simultaneously with opioids.

In 66 of the 87 dermatologic procedures, the workgroup determined postoperative opioids were unnecessary.

“We recommend a maximum prescription of 10 oxycodone 5 mg morphine equivalents for 20 of the 87 procedural scenarios and a maximum of 15 oxycodone 5 mg pills for only one of the 87 procedural scenarios,” McLawhorn and colleagues wrote.

The panel did not achieve consensus for pain management for five procedural scenarios: Karapandzic flaps, en bloc nail excisions, facial resurfacing with deep chemical peels, and small- or large-volume liposuction.

“[R]ather than a simple standardization of the opioid pill counts, we propose that providers reference these guidelines to estimate the amount of [morphine milligram equivalents] that is needed to adequately treat, not necessarily eliminate, acute postoperative pain,” McLawhorn and colleagues wrote. – by Abigail Sutton

Disclosures: The authors report no relevant financial disclosures.