Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus

Abstract

BACKGROUND Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence. OBJECTIVE To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction. METHODS This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval. RESULTS Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid. CONCLUSION Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

Dermatologic surgery opioid prescribing recommendations in practice

“…1 The lack of available evidence limited the scope of the original review to nonsurgical interventions despite the authors' acknowledgment that many guidelines credit surgery as being inexpensive, safe, and effective. 2 A total of 9 studies, encompassing 363 participants, were included for review. There were no trials investigating surgical treatment available for inclusion, and, consequently, the 9 included studies examined only nonsurgical interventions.…”

“…2,3 They provide guidance as to which dermatologic procedures necessitate opioids for pain control. In the 2020 guidelines by Donigan et al, 2 a consensus was reached to not routinely prescribe opioids for most complex linear repairs (CLCs) (excluding the nail unit and scalp [2.5 cm) or \20 cm 2 full-thickness skin grafts (FTSG) after Mohs micrographic surgery (MMS). Consensus was not reached for linear closures of [2.5 cm on the scalp or CLC or FTSG of the nail unit.…”

“…Consensus was not reached for linear closures of [2.5 cm on the scalp or CLC or FTSG of the nail unit. 2 In the 2021 expert panel consensus by McLawhorn et al, 3 opioids were not recommended for any linear closures or FTSGs. The primary goal of our study was to compare the recent guidelines to national patient opioid fill rates for post-MMS FTSG and CLC reconstructions from 2009 to 2020.…”

Managing pain associated with dermatologic procedures

“…In patients with severe pain that is inadequately controlled with acetaminophen and NSAIDs, opioids may be necessary, especially following flap repairs of the scalp, ear, nose, cheek, lip, and perineum 48 . However, opioids are not typically required following dermatologic surgery, and a recent Delphi consensus study using a panel of Mohs surgeons found no scenario for which consensus was met to routinely prescribe opioids following Mohs surgery 49 . Due to the many potential side effects and risk of dependency, opioids should only be prescribed at the lowest efficacious dose and used in combination with nonopioid therapies 50 .…”

“…48 However, opioids are not typically required following dermatologic surgery, and a recent Delphi consensus study using a panel of Mohs surgeons found no scenario for which consensus was met to routinely prescribe opioids following Mohs surgery. 49 Due to the many potential side effects and risk of dependency, opioids should only be prescribed at the lowest efficacious dose and used in combination with nonopioid therapies. 50 When opioids are required following dermatologic procedures, it is typically for less than 36 hours postoperatively.…”