Personalized Opioid Prescribing With an Individualized Tapering Protocol Following Orthognathic Surgery Reduces the Amount of Unused Opioid.

BACKGROUND

Orthognathic surgery may result in opioid prescribing that exceeds patient need, creating surplus medication.

PURPOSE: To compare unused hydromorphone after orthognathic surgery between personalized inpatient-use-based prescribing with tapering and standardized fixed-dose prescribing.

STUDY DESIGN, SETTING, AND SAMPLE: Prospective single-center randomized trial (Dalhousie University, Halifax, Nova Scotia; April 2023-April 2024). Adults undergoing single- or double-jaw orthognathic surgery were stratified and then randomized by 1:1 block randomization.

PREDICTOR VARIABLE: Postoperative analgesic protocol, being a standardized opioid prescription (SOP) or personalized opioid prescription (POP) based on inpatient opioid use with individualized tapering.

PRIMARY OUTCOME VARIABLE: Unused hydromorphone at 2 weeks, measured in milligrams. Secondary outcomes included opioid consumption, prescription amount, pain scores, satisfaction, and unanticipated opioid prescriptions.

COVARIATES: Age, sex, body mass index, American Society of Anesthesiologists classification, psychiatric history, substance use, surgical plan, operative duration, anesthesia type, corticosteroid dosing, preoperative anxiety, inpatient hydromorphone use, and nonopioid analgesic use.

ANALYSES: Median unused hydromorphone was compared between groups using Mann-Whitney U tests. Categorical variables were compared using χ2 or Fisher's exact tests. Negative binomial regression evaluated the association between prescribing protocol and unused hydromorphone after baseline covariate adjustment. Statistical significance set at P < .05.

RESULTS

201 subjects were enrolled; 151 completed the study (74 SOP; 77 POP; 25% attrition). Mean age was 31.4 years (SD, 10.9), and 95 subjects (63%) were female. Unused hydromorphone was lower with POP than SOP after single-jaw surgery with a median of 4.0 mg (interquartile range [IQR], 3.0 to 6.0) versus 36.5 mg (IQR, 15.0 to 40.0; P < .001), and after double-jaw surgery at 4.0 mg (IQR, 3.5 to 4.8) versus 29.0 mg (IQR, 18.5 to 40.0; P < .001). Following multivariable adjustment, hydromorphone surplus was associated with POP assignment (incidence rate ratio, 0.19; 95% CI, 0.14 to 0.26; P < .001) and female sex (incidence rate ratio, 0.71; 95% CI, 0.53 to 0.94; P = .02). Postoperative hydromorphone consumption was lower across all surgeries with POP at 1.0 mg (IQR, 0.0 to 6.0) versus 7.0 mg (IQR, 0.0 to 24.5; P = .01). Pain scores were similar between groups (P = .7). Satisfaction was similar in the single-jaw cohort between SOP and POP and was higher in POP after double-jaw surgery: 22.0 (IQR, 19.0 to 24.0) versus 19.5 (IQR, 15.0 to 21.0; P = .004).

CONCLUSION

Personalized opioid prescribing after orthognathic surgery reduced absolute postoperative opioid surplus without compromising pain control or satisfaction.