Pain management in sinonasal surgery: are opioids required?

Abstract

With the United States in the throes of an opioid abuse epidemic, significant attention has been focused on physician prescriptions, and the potential diversion of medications as a conduit toward opioid addiction. In 2014, opioid addiction was estimated to affect 2.5 million adults in the United States. In terms of drug overdose deaths, 37% of the 44,000 overdose deaths reported in 2014 were attributed to opioids.1 Certainly, prescription drugs are seen as a less threatening alternative for obtaining drugs than are purchases from a drug dealer. Indeed, in 1 study of schoolchildren in grades 7 to 12, 30% believed that prescription pain relievers are not addictive.2 Additionally, the focus on inpatient and outpatient pain symptoms may have exacerbated opioid prescribing. In 2000, the Joint Commission unveiled its pain management standards, with the premise that “excuses for inadequate pain control appear to have run their course and will no longer be accepted because poor pain control is unethical, clinically unsound, and economically wasteful.” This created a major clinical focus, uniformly utilizing an in-hospital visual analog scale and making pain the “5th vital sign to be monitored.”3 Obviously, none of us wish to see our patients in pain postoperatively, and I do not believe that my patients have become addicted from their short term pain management, although evidence shows that this can occur. However, I have no idea how many of the pills that I have provided in the past have been diverted to other individuals or perhaps even taken by adolescents. Recognition of this is a strong impetus toward providing appropriate pain relief, but also toward minimizing the possibility of overprescribing. In this issue of the International Forum of Allergy & Rhinology (IFAR), several articles further evaluate the issue of postsurgical pain and its management. Riley et al.4 evaluate pain in postoperative endoscopic sinus surgery (ESS) and septoplasty with a visual analogue scale (VAS) and medication usage over a 2-week period. Patients had an average of 27 of 30 opioid pills left over at the end of the study, and the authors identified that the pain decreased rapidly during the first 3 days. In another article, Khanwalkar et al.5 evaluate the utilization of a mobile digital patient engagement