The opioid epidemic is a multifaceted and complex issue that has significantly impacted people in the United States. Pain management following surgery continues to be one of the many areas in which providers can attempt to reduce overprescribing and misuse of opioids. In dermatology, there are few guidelines on the use of opioids following dermatologic procedures. Justin M. McLawhorn, MD, resident physician with the department of dermatology at the University of Oklahoma College of Medicine, and his colleagues created recommendations to help guide dermatologists on selecting appropriate pain management medications following a dermatologic procedure.1 Their guidelines include:
- Acetaminophen and ibuprofen can adequately manage postoperative pain for most uncomplicated procedures.
- No specific scenario in dermatology requires more than 15 oxycodone 5 mg oral equivalents to manage postoperative pain.
In an interview with The Dermatologist, Dr. McLawhorn discussed the guidelines and how dermatologists can reduce unnecessary opioid prescribing in dermatology.
The Dermatologist: Why did you and your team decide to create these recommendations? Do you expect this to help address inappropriate prescribing of opioids in dermatology?
Dr McLawhorn: We wanted to help address the overprescribing of opioids in dermatology as the opioid crisis has reached epidemic proportions. Recent evidence suggests that nearly 6% of post-surgical, opioid-naïve patients become long-term users of opioids. The lack of specific evidence-based recommendations likely contributes to a wide variety in prescribing patterns and a steady supply of unused opioids.
Countering the opioid crisis necessitates a restructuring of the opioid prescribing practices that addresses pain in a procedure-specific manner. These recommendations are one tool in the dermatologists’ arsenal that can be used as a reference to help guide opioid management and prevent excessive opioid prescriptions at discharge following dermatologic interventions.
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The Dermatologist: What were some of the challenges for creating these guidelines?
Dr McLawhorn: Perhaps the most challenging aspect of the project was the recruitment of dermatologists from around the nation to participate in this months-long discussion. We convened a panel of board-certified dermatologists and tasked them with completing electronic surveys, some of which had more than 50 questions. We completed this discussion on an electronic REDCap format to allow our panel to convene without having to meet face-to-face. Creation of the online platform to allow for such a discussion proved to be a difficult, yet successful, venture.
The Dermatologist: How did you come to a consensus for managing post-procedure pain?
Dr McLawhorn: Our panel members decided which procedures routinely require opioids at discharge for uncomplicated cases. The recommendations were generated when a group majority (defined as 75% or more) of the panel members agreed on every procedure. That is to say, our panelist determined which procedures would routinely require opioids at discharge and provided a range of acceptable amounts.
The Dermatologist: You and your colleagues found no specific scenario in dermatology required more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Could you elaborate more on this finding and what that means for dermatologists?
Dr McLawhorn: Our panel did not identify any specific procedural scenario or intervention in dermatologic practice that would routinely require greater than 15 oxycodone 5-mg oral equivalents at discharge to manage postoperative pain. What this means is that any dermatologist who regularly prescribes more than 15 oxycodone 5-mg oral equivalents for any procedure should re-evaluate the need for such large number of pills/tablets.
We recognize that our panel did not address the use of prescribing opioids for patients who were not opioid-naïve or for patients who are on chronic opioid management for pain unrelated to the procedure/intervention. Also, we recognize that patient-specific factors including patients’ tolerance of pain, medical comorbidities, and intra/postoperative complications may necessitate opioid management and for longer periods of time. It is for this reason that our guidelines cannot be used as a one-size-fits-all but rather must be used in combination with clinical judgement to formulate an effective pain management plan for each patient.
The Dermatologist: What are your recommendations for providers when determining whether to prescribe an opioid following a dermatologic procedure? In addition, do you have any recommendations for addressing opioid use disorder?
Dr McLawhorn: We recommend that every dermatologist address postoperative pain on a case-by-case basis but also to be conscientious and judicious in their use of opioids. We encourage dermatologists to refer to our guidelines as a starting point to help formulate an effective and responsible pain management plan for their patients.
Addressing opioid-use disorder is beyond the scope of dermatology and may require a multidisciplinary team of primary care providers, pain-management specialists, and psychiatrists to address the underlying pathology that lead to or perpetuates the addiction or physiologic dependence on opioid analgesics.
The Dermatologist: What other areas of future research are needed to develop evidence-based guidelines?
Additional research is needed to determine the efficacy of acetaminophen and non-steroidal anti-inflammatory drugs in the treatment of postoperative pain following dermatologic procedures/interventions. We provide these recommendations that are consensus-based in lieu of quality evidence-based and procedure-specific recommendations. Management of chronic pain is complex and requires a multidisciplinary approach. Furthermore, an understanding of the complex nature and cause of pain is not completely understood.
I would like to thank our panel of expert providers for dedicating their time and efforts to address such an important topic in dermatology. I am indebted to our collaborators and senior authors of the guidelines, Drs. Collins and Stasko with the department of dermatology at the University of Oklahoma College of Medicine, for their leadership and insight in carrying out this project.
1. McLawhorn JM, Stephany MP, Bruhn WE, et al. An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures [published online November 12, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.09.080