Patients about to undergo Mohs microscopic surgery reported that they were more likely to request over-the-counter medications if they perceived their risk of opioid addiction to be high.
Patients who receive Mohs surgery seriously consider the risk of opioid addiction when selecting pain medications, according to a prospective study published in JAMA Dermatology.
Findings suggest that when the perceived risk of opioid addiction is low (0%), 50% of respondents would consider opioids in addition to over-the-counter (OTC) medications if their pain level reached a 6.5 on a 10-point scale (90% CI; 5.7-7.5).This equal preference for opioids diminished as the risk of opioid addiction increased. When the risk of opioid addiction was slated at 2%, 6%, and 12%, patients reported that they would prefer OTC medications alone, regardless of pain.
“As the theoretical risk of opioid addiction increased, patients preferred only OTCs despite high levels of pain,” Shannon T. Nugent, MD, a resident of Penn Medicine Dermatology, and co-investigators wrote in the study. “These study findings highlight the need for shared decision-making discussions with patients to determine individualized postoperative pain control regimens.”
Between June 2009 and June 2020, approximately 26% of patients who received Mohs micrographic surgery received an opioid prescription. This percentage of patients increased to 39.6% in 2011 and decreased to 11.7% in 2020. Although the average duration of opioid use following a Mohs micrographic surgery is short, averaging between 3 to 5 days, in other medical specialties, short-term opioid use following surgery is associated with an increased risk of long-term use. The risk of long-term opioid use following Mohs micrographic surgery is not well understood. Therefore, investigators sought to understand how the risk for potential long-term opioid use factored into patient decision-making.
This study was conducted out of a single academic medical center between August 2021 and April 2022. The prospective survey was sent out via the Conjointly platform, and data were assessed between May 2022 and February 2023. Each patient completed the survey once, along with their caregiver.
The study’s primary objective was to determine the pain threshold at which half of respondents would choose OTCs plus opioids over OTC alone for pain management. Investigators sought to identify this pain threshold across varying risk profiles (low, 0%; low-moderate, 2%; moderate-high, 6%; high, 12%). The survey asked participants to weigh the potential benefit of improved pain control vs the risk of opioid addiction by presenting them with 12 difference scenarios.
A total of 342 eligible participants began the survey; 295 patients completed it (86%). The mean age was 64.6 years (range, 22-94), and most (59%) participants were female. The survey did not consider race and ethnicity. Of note, 20% of respondents (n = 59) worked in health care.
Among those who responded, 70.2% (n = 207) had already been prescribed an opioid, 34.2% expressed that they would never consider taking an opioid, and 49.8% (n = 147) shared that they were concerned about the risk of opioid addiction. Patients who had already received opioids were more likely to accept treatment with OTC plus opioids compared to those with no prior opioid experience. Of note, across all scenarios, those had previously been prescribed opioid still preferred to only receive OTC treatment.
Among the 296 respondents, 50% stated that possible opioid addiction was a consideration in selecting a pain management strategy while 34% stated that they would never consider opioids, regardless of their pain level. Seventy-six percent of respondents expressed that they would only want to receive over-the-counter medications vs OTCs plus opioids.
Study authors noted that the single-center design served as a limitation for this study. Moreover, the study included a high percentage of health care workers and individuals with relatively higher education and household income. Lastly, they acknowledge that a prospective study does not capture actual behavior, and that respondents who are in active pain may respond differently than they would in hypothetical scenarios. Regardless, the findings demonstrate that patients are concerned about limiting their risk of opioid addiction, and this may drive future patient discussions.
“These findings may spur research investigating the risk of long-term opioid use after [Mohs micrographic surgery] and provide a framework for Mohs surgeons to engage in shared decision-making discussions with patients moving forward,” study authors concluded.
Nugent ST, Veerabagu SA, Madden M, et al. Patient preferences for pain control after mohs micrographic surgery: a single-center discrete choice experiment. JAMA Dermatol. Published online July 5, 2023. doi: 10.1001/jamadermatol.2023.1899.