An Analgesic Regimen for Opioid Reduction in Elective Plastic Surgery

A Randomized Prospective Study

Ashley Newman, B.S.; Steven P. Davison, M.D., D.D.S.


Plast Reconstr Surg. 2021;147(2):325e-330e. 

In This Article


Multimodal analgesia approaches have been increasingly popular across many specialties. These approaches give the opportunity for physicians to decrease the amount of circulating opioids, while also improving many patient outcomes. Although the prescribing of opioids after elective cosmetic surgery may be common, with fewer circulating opioids, there is a lower probability of misuse and abuse.

As the United States prescribes 90 percent of the world's opioid pain medication, and 80 percent of prescribed pills go unused, we are creating an enormous opioid reservoir.[22] This was shown by the objective nature of this study and the results; patients kept their bottles of pain medication and postoperatively counted the pills at the 1-month follow-up appointment.

This study analyzed the effects of a multimodal analgesia approach on patients undergoing elective cosmetic surgery. Patients receiving multimodal analgesia were compared to patients receiving a standard opioid-based medication regimen. There was no significant difference in the demographics in each group, nor was there any significant difference in procedure frequency (breast, facial, and body procedures) or length. All procedures were performed by the same surgeon under similar conditions, including general anesthesia and the use of local anesthetic. In this study of 143 patients, it was demonstrated that the use of multimodal analgesia in the preoperative and postoperative periods translated to a decrease in pain scores in the postanesthesia care unit and discharge. The consistent, blinded postanesthesia care unit nurse gave equivalent doses of opioids to each group, which reflects a treating pattern. However, the patients still experienced a 21.2 percent greater reduction in pain. Outcomes in all pain score reductions were found to be statistically significant, with a 13.0 percent reduction in postanesthesia care unit pain assessment and a 34.2 percent reduction in pain scores at discharge. The amount of opioids required for patient discharge in the postanesthesia care unit was lower for the multimodal analgesia group (calculated as morphine equivalents), but no significant difference was found at a 95 percent confidence interval. It is useful to note that the number of opioid pills taken in the postoperative period was significantly less in the multimodal analgesic regimen group, representing a 35.0 percent reduction in the number of opioid pills taken. Each patient was given a prescription that included 30 opioid pain pills. Patients using the multimodal regimen used an average of 7.7 ± 5.3 opioid pain pills in the postoperative period, whereas traditional opioid patients used an average of 11.9 ± 8.4. This demonstrates that we overprescribed opioids in the postoperative period. Our new protocol is to prescribe no more than 24 opioid pain pills, which is two times the average taken during the postoperative period.

The cost to a patient on the multimodal analgesia regimen compared to the standard opioid regimen was $8.58 more, out of pocket, and would likely be less for a patient who has medical insurance.[22–26] The cost to the surgical facility is $2.40 per patient and includes the price to stock both acetaminophen and gabapentin for use in the preoperative area.[23–27] The cost to the patient and facility to use the multimodal analgesic approach discussed here is marginal considering that patients have less pain, take less opioids, and are more satisfied. Furthermore, the amount of prescribed opioids in circulation is decreased. The multimodal analgesic regimen discussed used the preloading of nonopioid pain medication in the preoperative area, which few studies have included. We chose oral acetaminophen versus the more expensive intravenous acetaminophen. In the future, we would consider using intravenous acetaminophen to assess further improvement in regimen adoption. It may also be considered that beginning gabapentin dosing the evening before surgery could prove to be more therapeutic.

The practice standard opioid prescription was typically 40 opioid pain pills for the postoperative period. The results of this study demonstrate that we are consistently overprescribing, which is contributing to the opioid reservoir. Practices must evaluate their prescribing policies to decrease the amount of opioids in circulation and thus decreasing the risk of abuse. In reality, this study shows that 15 tablets is adequate for the average patient, absent a multimodal enhanced recovery after surgery program. The American Society of Plastic Surgeons 2018 statistics report 1,811,740 cosmetic surgical procedures in 2018.[18] If surgeons had prescribed 40 opioid pain pills for each of these operations, this would be 72,469,600 pills at a cost of $42,273,933.31 in oxycodone alone, given the multimodal protocol discussed in this article. If we reduce the number of pain pills theoretically prescribed to 25, this would have been a total of 45,293,500 pills at a cost of $26,421,208.32. If we reduce the number of oxycodone pills prescribed to 15 tablets for a total of 27,176,100, which is sufficient according to the data presented, the cost would have been $15,852,724.99. This represents a possible decrease of 45,293,500 pain pills and a 62.5 percent change in cost yearly if each of these surgeons decreased their prescriptions by 25 tablets.

Although the sample size is small, this study represents promising data for the use of enhanced recovery after surgery protocols in cosmetic elective procedures, and a likely extension in reconstructive surgery. Any confounding of the results was minimized by a similar spectrum of surgery in each group as opposed to one procedure only. The operations that are isolated are common enough for large group comparison. The postanesthesia care unit nurse's usual and customary practice was to respond to the individual pain level. This study used one postanesthesia care unit nurse, so there was no confounding on practice patterns.