Dermatologists Issue Guidelines for Opioid Management Following 87 Common Procedures

Routine opioid prescriptions are unnecessary for 66 common dermatologic procedures.

New dermatologic procedure-recommendations for opioid management seek to help curtail the opioid epidemic and reduce the number of opioid overdose deaths.

The new consensus statement was developed by a group of 40 board-certified dermatologists, including Mohs micrographic surgeons, dermatopathologists and cosmetic dermatologists and appears online in the Journal of the American Academy of Dermatology.

According to the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), overdose deaths involving prescription opioids increased nearly 400 percent from 1999 to 2017. In 2017, more than 70,000 Americans died from drug overdoses, and almost 68 percent of these deaths involved a prescription or illicit opioid. While the CDC has released general opioid prescribing recommendations for health care providers, there remains a need for guidelines that are specific to dermatologic procedures to address variation in prescribing patterns and practices.

“The hope is that this will serve as a tool to help safely guide the management of patients’ post-procedural pain,” says board-certified dermatologist and Mohs surgeon, Lindsey Collins, MD, FAAD, who played a key role in the guidelines’ creation. “We think it will help curb potential opioid misuse by addressing pain in a procedure-specific manner.”

After extensive discussion, the panel of dermatologists developed recommendations for 87 of the most common dermatologic procedures, measured by morphine milligram equivalents (MME):

• Routine opioid prescriptions are unnecessary for 66 of the procedures, as these can be adequately managed with acetaminophen and/or ibuprofen.
• A prescription of 1-10 opioids (equal to oxycodone 5mg) for the duration of the patient’s recovery may be necessary for 16 of the procedures, including scalp and cheek reconstruction.
• A prescription of 1-15 opioids (equal to oxycodone 5mg) for the duration of the patient’s recovery may be necessary for only one of the procedures: upper lip reconstruction, known as the Abbe flap.
• No procedure routinely requires more than 15 opioids (equal to oxycodone 5mg).

Lead study author and dermatology resident at the University of Oklahoma Health Sciences Center Justin McLawhorn, MD, says that many of the procedures that require 1-10 opioids are performed by dermatologists and Mohs surgeons on a daily basis. In comparison, the sole scenario requiring up to 15 opioid tablets is a complex repair that is not often performed. He also pointed out that the recommendations are presented in a quick-reference manner, enabling dermatologists to easily consult the suggested personalized pain management for their patients.

As Dr. McLawhorn notes, the guidelines are not meant to be a one-size-fits-all solution and are only meant to apply to patients who do not experience any complications during or after the procedure. He suggests that dermatologists should have a discussion with their patients about their expectations for managing post-procedural pain, including the risks of opioid use. “These recommendations must be individualized to accommodate each patient on a case-by-case basis while ensuring that all patients receive safe, effective pain treatment,” he said. “The guidelines are another tool in dermatologists’ arsenal that can be used to provide adequate pain counseling for patients undergoing these procedures.”

The authors are also hopeful that the new recommendations will resonate with patients. “We think patients will appreciate that their dermatologists are taking steps to limit the over-prescription of opioid pills,” says Dr. Collins.

The CDC warns that taking prescription opioids for long periods of time can increase the risk of addiction and overdose, yet despite the evidence of potential for abuse and misuse of opioids, more than 191 million opioid prescriptions were given to American patients in 201

Statistics such as this one, say the authors, make these guidelines all the more timely and crucial for dermatologists to help lead and serve as patient advocates in confronting the opioid crisis. “Countering the opioid epidemic will require physicians to re-evaluate their current practice patterns, and we are providing this tool for dermatologists as a starting point to reduce opioid addiction and opioid-related deaths,” adds Dr. McLawhorn. “These guidelines are one step in the process of producing meaningful change in the prudent use of opioids.”