Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction

Abstract

Introduction: Currently, there is no consensus regarding the role of opioids in the management of perioperative pain in children undergoing cleft lip/palate repair. Method: The present study evaluated opioid prescribing patterns of surgeon members within the American Cleft Palate-Craniofacial Association surgeons utilizing an anonymous survey. Results: Respondents performing cleft lip repair typically operate on patients 3 to 6 months of age (86%), admit patients postoperatively (82%), and discharge them on the first postoperative day (72%). Comparatively, respondents performed palatoplasty between the ages of 10 and 12 months (62%), almost always admit the patients (99%), and typically discharge on the first postoperative day (78%). Narcotics were more frequently prescribed after palatoplasty than after cleft lip repair, both for inpatients (66%; 49%) and at discharge (38%; 22%). Oxycodone was the most prescribed narcotic (39.1%; 41.4%), typically for a duration of 1 to 3 days (81.5%; 81.2%). All surgeons who reported changing their narcotic regimen (34.4% dose, 32.8% duration) after cleft lip repair, decreased both parameters from earlier to later in their career. Similarly, surgeons who changed the dose (32.2%) and duration (42.5%) of narcotics after palatoplasty, mostly decreased both parameters (96%). Additionally, physicians with >15 years of practice were less likely to prescribe opioids in comparison with colleagues with ≤15 years of experience. Ninety-two percent of respondents endorsed prescribing nonopioid analgesics after prescribing cleft surgery, most commonly acetaminophen (85.7%; 85.4%). Conclusion: Cleft surgeons typically prescribe opioids to inpatients and rarely upon discharge. Changes to opioid-prescribing patterns typically involved a decreased dose and duration.

Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter?

“…1 Our data suggest that opioid prescribing has significantly decreased over the past 5 years for children undergoing unilateral (P < .001) and bilateral (P = .004) cleft lip repair, which is consistent with a recent survey of cleft surgeons. 9 That survey also noted that surgeons with greater than 15 years of experience were less likely to prescribe narcotics postoperatively. 9 White patients and those with Medicaid enrollment have been noted to have higher opiates prescribed in the general population, 31 which is fairly consistent with our study noting that White patients with below-median household income (P = .015) and those with government insurance (P = .005) were more likely to be prescribed opioids after cleft lip repair.…”

“…9 That survey also noted that surgeons with greater than 15 years of experience were less likely to prescribe narcotics postoperatively. 9 White patients and those with Medicaid enrollment have been noted to have higher opiates prescribed in the general population, 31 which is fairly consistent with our study noting that White patients with below-median household income (P = .015) and those with government insurance (P = .005) were more likely to be prescribed opioids after cleft lip repair. Multimodal analgesia regimens utilizing nonsteroidal antiinflammatory drugs (NSAIDs) in children undergoing cleft lip repair may have the minor theoretical disadvantage of increasing postoperative bleeding risk, such that some advocate delaying its administration for 12 h after a cleft lip or palate repair, 32 which precludes its effective utilization in the immediate perioperative period.…”

“…Cleft lips are generally repaired between 3 and 6 months of age, 9 and some surgeons have begun to perform these procedures in the neonatal period, 23 despite evidence that earlier surgery may increase perioperative risk. 24,25 Narcotic utilization in infants and young children has a greater risk of respiratory depression, airway compromise, and death.…”

“…Narcotic utilization in neonates and infants increases the risk for respiratory depression and chronic dependence. [1][2][3][4][5][6][7][8] Although narcotic administration after cleft lip repair has been decreasing, 9 there is no consensus on the optimal local anesthetic formulation for these procedures to minimize perioperative pain. In addition to the intuitive benefits of patient comfort and mitigating attendant risks of opioid administration, better pain control in the immediate and extended perioperative period may also provide the advantage of decreased wound disruption.…”

“…In addition to the intuitive benefits of patient comfort and mitigating attendant risks of opioid administration, better pain control in the immediate and extended perioperative period may also provide the advantage of decreased wound disruption. 9 Local anesthetic administration might mitigate postoperative pain and minimize opioid requirements. Short-acting local anesthetics (eg, lidocaine) provide intraoperative pain relief, but their therapeutic effects are relatively brief, whereas long-acting local anesthetics (eg, bupivacaine) have the benefit of prolonged pain relief after emergence from anesthesia.…”