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

Abstract and Introduction


Background: Prescription opioid misuse has been recognized as a national epidemic. The implications of this problem are especially important to consider, as postoperative opioid abuse can give rise to true addiction for surgical patients. The concept of enhanced recovery after surgery is increasingly used across various specialties to decrease the overabundance of postoperative opioid use.

Methods: This study prospectively examined 143 patients undergoing cosmetic elective surgery. Patients were randomized into one of two groups based on postoperative pain management regimen: multimodal (enhanced recovery after surgery) analgesia or traditional opioid analgesia. Data regarding postoperative pain scores, amount of postoperative opioids consumed, and duration of postoperative pain pill use were analyzed.

Results: Multimodal (enhanced recovery after surgery) regimen patients experienced a 13.0 percent reduction in their pain scores after admission to the postanesthesia care unit and a 34.2 percent reduction in pain score at discharge, compared with traditional opioid patients (p = 0.049 and p = 0.0036, respectively). Enhanced recovery after surgery patients experienced a 35 percent reduction in the number of pills taken in the postoperative period and an 18.4 percent reduction in the duration of consumption (p = 0.0007 and p = 0.0539, respectively).

Conclusions: The results demonstrate that multimodal postoperative pain management is an important tool for decreasing the amount of opioids prescribed and needed in the postoperative period. The overprescribing of opioids after surgery is a precursor to abuse and the increase in the national opioid reservoir.

Clinical Question/Level of Evidence: Therapeutic, II.


Prescription opioid misuse has been recognized as a national epidemic. The implications of this problem are especially important to consider, as postoperative opioid abuse can give rise to true addiction for surgical patients. Of the 33,000 deaths caused by opioid overdose in 2015, half were attributable to prescription opioids.[1] Use of opioid medication is often a necessary part of postoperative analgesia, but many physicians fall short when it comes to prescribing opioids judiciously and recognizing the potential for long-term addiction. The use of multimodal analgesic regimens is an effective strategy to decrease the amount of opioids prescribed to patients.[2]

In a study of 39,140 patients undergoing elective surgery, it was found that nearly half of the patients were discharged with an opioid prescription, showing that surgeons do not hesitate in using opioid analgesics beyond the immediate postoperative period (Figure 1).[3] In this same study, 3.1 percent of patients were still using opioids more than 90 days after surgery.[4] When patients are on opioids for longer periods following surgery, they are more likely to build tolerance and become addicted to these medications.[5,6] This is crucial to considering patient safety, as the number of opioid-related deaths has been a rising epidemic for several decades.[6,7] It has been estimated that there is a 44 percent increase in misuse for every opioid prescription refilled, which corresponds to a 20 percent increase in misuse for every week of prescription.[5,8] Despite the rising numbers of deaths and increasing reports of misuse, surgeons have yet to find the right balance of opioid prescription. Between 3 and 10 percent of opioid-naive patients become chronic users, and as many as 80 percent of prescribed pills go unused.[9,10]

Figure 1.

Prevalence of opioid abuse in patients by specialty. (Reprinted with permission from Jiang X, Orton M, Feng R, et al. Chronic opioid usage in surgical patients in a large academic center. Ann Surg. 2017;265:722–727. DOI: 10.1097/SLA.0000000000001780.)

In a more recent study, it was found that new persistent opioid use after surgery is common and is associated with behavioral and pain disorders, suggesting that misuse is attributable not solely to surgical pain but to addressable patient-level predictors such as age, sex, race, education, family history, tobacco use, mood disorders, comorbidities, socioeconomic status, and presence of preoperative pain.[11] The concept of enhanced recovery after surgery was developed in 1997, and is increasingly used across various specialties.[12,13] Enhanced recovery after surgery allows for multidisciplinary and multimodal approaches to perioperative care, including preoperative counseling, nutrition plans, anesthetic and analgesia regimens, and early mobilization.[14–19] Implementation of multimodal analgesic regimens can decrease opioid consumption and the ensuing related complications. Enhanced recovery after surgery protocols have also been demonstrated to decrease health care expenditures and increase overall patient satisfaction.[20] In a recent review, it was found that there was no increased risk of adverse events when using some medications (e.g., intravenous acetaminophen, ketamine, liposomal bupivacaine, and gabapentin) as opioid alternatives.[21] This randomized prospective study was designed to determine the effectiveness of multimodal (enhanced recovery after surgery) pain management protocols in elective plastic surgery patients.