QWhen are opioids indicated in Mohs surgery?

I remember learning in medical school that the goal of pain management is not the absence of pain, but to reduce pain so patients can function in their day to day lives with minimal interruption from their typical activities and sleep. My goal of pain management in my Mohs practice is to minimize pain so patients can function in their everyday lives and sleep well.

For most patients, their pain will typically be present for 1-2 days and will be comfortable with acetaminophen and/or ibuprofen. I will encourage patients to start with acetaminophen taking 2 325 mg tablets/capsules every 6 hours, but not to exceed 3000 mg in a 24 hour period. If this does not address the pain, I will have them alternate between acetaminophen and ibuprofen once every 3 hours.  Ibuprofen dosing is 400 mg at each dose every 6 hours. If a patient takes acetaminophen at 1 PM, they would take ibuprofen at 4 PM, then acetaminophen at 7 PM, alternating every 3 hours. There is evidence that this can be even more effective than acetaminophen and codeine for postoperative pain relief from Mohs Surgery.¹ There are limitations to using ibuprofen as well in patients with kidney disease, GI bleed history, or are at higher risk for bleeding postoperatively.

In my Mohs practice, I try to limit opioid prescription as much as possible. I probably prescribe opioids less than 10 times a year, if that. There is a possibility of becoming addicted to opioids even after only 5 days of treatment. However, there are times I am more likely to prescribe an opioid. Large flaps performed on highly sensitive locations such as lips, ears, noses, and high tension repairs, especially on scalps, may warrant an opioid prescription. I also provide my cell phone number to patients so if they are having significant pain by 7 PM that is not well controlled with over the counter analgesics, they can contact me. I am typically more concerned about an underlying cause of significant pain, such as a rapidly expanding hematoma. I can call in a prescription for 5 capsules/tablets of tramadol as needed if an underlying cause of significant pain, such as a hematoma, has been ruled out. However, many patients with larger flaps do not require utilizing opioids even if prescribed. If after discussion of the risks and benefits of an opioid treatment for pain, including operating heavy machinery such as a car, the patient would benefit from opioids, I will use E-FORCSE when prescribing to ensure the patient is not at high risk for abuse of opioids. I will typically provide only 5 capsules/tablets of hydrocodone/acetaminophen 5/325 with no refills. I will also encourage the patient to only fill the prescription if the pain cannot be controlled by acetaminophen and ibuprofen. The patient is encouraged to not complete the full prescription if not necessary for pain control.

There is a role for opioids in Mohs surgery, however, in my opinion, it is very limited.  Fortunately, most patients receive pain relief from over the counter analgesics.

Reference

1. Sniezek, Patrick J., David G. Brodland, and John A. Zitelli. “A randomized controlled trial comparing acetaminophen, acetaminophen and ibuprofen, and acetaminophen and codeine for postoperative pain relief after Mohs surgery and cutaneous reconstruction.” Dermatologic surgery 37.7 (2011): 1007-1013.