Guidelines Address Opioid Prescribing for Common Dermatologic Procedures

By Marilynn Larkin

November 27, 2019

NEW YORK (Reuters Health) - An expert panel has produced consensus guidelines for managing pain in opioid-naïve patients after 87 common dermatologic procedures.

"The defining feature of these guidelines is that they are procedure-specific," Dr. Justin McLawhorn of of the University of Oklahoma Health Sciences Center in Oklahoma City told Reuters Health by email. "We sought to create these guidelines as there is much ambiguity in the recommendations that have been adapted for use in dermatologic surgery."

As reported online November 12 in the Journal of the American Academy of Dermatology, the guidelines were developed in a "systematic discussion" with providers in general dermatology, dermatologic surgery, and cosmetics/phlebology.

The guidelines take into consideration the procedure, anatomic structures manipulated during the procedure, and the expected wound healing process.

Opioid tablets were defined as oxycodone 5-mg oral equivalents.

Overall, the panel concluded that postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. No procedure routinely requires more than 15 oxycodone 5-mg oral equivalents.

Twenty-three percent of the procedural scenarios discussed routinely require 1-10 opioid tablets, while only one (Abbe flap for lip reconstruction) routinely requires 1-15 opioid tablets.

When non-opioid management is recommended, patients should be provided with specific instructions to schedule and/or stagger over-the-counter medications to provide appropriate relief in the postoperative period with one gram of acetaminophen every eight hours and/or 400 milligrams of ibuprofen every four hours.

When opioids are required, they should be used concomitantly with acetaminophen and/or non-steroidal medications, according to the panel. Alternatively, combined opioid and acetaminophen/non-steroidal medications may be prescribed, at the recommended equianalgesic dose, to improve pain control and minimize the exposure to opioids.

A table with the recommended opioid doses for specific procedures is provided in the paper.

Dr. McLawhorn said, "Our guidelines serve as a practicable benchmark for prudent use of postoperative opioids but are not meant to be used as a one-size-fits-all approach. Any pain management plan should be formulated with the patient and provider and should account for the expectations and comorbidities of the patient."

"Our hopes are that these guidelines can help to decrease the variation in opioid-prescription patterns and align outliers with the consensus recommendations of their peers," he noted.

"A literature review should not be needed to further substantiate these recommendations," he added. "However, it is important to bear in mind that these recommendations are the synthesis of discussions from experts in the field and are not meant to replace quality evidence-based research."

Dr. Suzanne Friedler, a clinical instructor of dermatology at the Mount Sinai Health System in New York City, said in an email to Reuters Health that she uses opioids "infrequently" in her practice, preferring ibuprofen and/or acetaminophen to achieve pain control.

For patients who don't tolerate pain well, she said, "I often employ opioids intraoperatively or during the procedure but do not continue them once patients are discharged home."

"There is great variability between what different patients are able to tolerate," she noted. "Patients who have fibromyalgia, depression or other neurological issues may be more sensitive to pain and require higher doses of analgesics. One must also consider the risk of chemical dependence, which is why I choose to keep the duration of opioid use very short."


J Am Acad Dermatol 2019.