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

Patients and Methods

This is a study on the feasibility and outcomes of an enhanced recovery after surgery protocol used in patients undergoing elective cosmetic surgery on an outpatient basis under general anesthesia. The study prospectively enrolled 143 patients between the ages of 18 and 67 years. This study design was presented and approved by the Institutional Review Board at Georgetown University, and the study practices used followed all the guidelines of the Department of Health and Human Services Regulations for the Protection of Human Subjects. All statistics were calculated using Microsoft Excel 2017 (Microsoft Corp., Redmond, Wash.) and MedCalc (MedCalc Software, Ostend, Belgium). All p values were calculated using a two-sample t test.

Patients were randomized preoperatively to either a standard opioid postoperative pain regimen or a novel multimodal analgesic approach. As part of the experimental protocol, patients in the multimodal (enhanced recovery after surgery) group were given 1 g of oral acetaminophen and 300 mg of oral gabapentin at least 1 hour before the start of surgery, in the preoperative suite. In this group, each patient was prescribed 300 mg of gabapentin orally every 8 hours for a total of 3 days, 650 mg of acetaminophen orally every 8 hours, and 5 mg of oxycodone orally every 4 to 6 hours for breakthrough pain. Patients were instructed to alternate the gabapentin and acetaminophen so that they were taking a pain medication every 4 hours (Table 1). The standard opioid postoperative protocol consisted of Percocet 5 mg/325 mg every 4 to 6 hours, with no preoperative medication given (Table 2). The dosing of Percocet 5 mg/325 mg every 4 to 6 hours, 4 g/day, was chosen based on practice preexisting prescribing habits. At the preoperative nursing appointment, each patient was randomized to a study group by the study coordinator. Patients were counseled by nurse and given protocol sheets to ensure that patients understood protocols. At mid study, the groups were analyzed to make sure they were comparable in procedure type and number of subjects in the group.

All operations were performed in the same outpatient surgery center, by the same surgeon, who was blinded to study arm. All operations were performed under general anesthesia, and patients were given pain medications during surgery at the discretion of the anesthesiologist, who was blinded to the study arm, and presumably managed the anesthetic and analgesic plans similarly. All patients received local anesthetic, or regional blocks specific for the case, during surgery. No regional blocks with long-acting pain medication were used, to avoid confounding effects. Some operations did involve combinations of procedures in more than one area (e.g., liposuction of the body with mastopexy), but no cases involved more than two areas in a single procedure. In the postanesthesia care unit, patients were given pain medications to include one or more of the following: Valium, Vicodin, oxycodone IR, fentanyl, Percocet, or Dilaudid. All medications in the postanesthesia care unit were given as needed, based on pain scores, at the discretion of the consistent postanesthesia care unit nurse, who was also blinded to study arm. Patients were asked to rate their pain on a 0- to 10-point Likert scale 30 minutes after arriving to the postanesthesia care unit and at discharge. The endpoint for discharge was standard eating, drinking, and pulse oximetry over 96 percent on room air, and pain at or below a 4 on the Likert pain scale. Morphine equivalency tables were used to determine the amount of opioids given to each patient in the postanesthesia care unit.

During the postoperative phone call, 1 day after surgery, patients were counseled on their medication protocol once again and asked to record the day they stopped taking all opioid pain medications. Patients were also asked to bring in pill bottles to determine how many opioid pain pills were taken in the postoperative pain period. Excess pills were properly disposed of by nursing staff. Patients were finally asked to report whether or not they were satisfied with their postoperative pain management (yes or no).