The Future Of Opioid Use In Plastic Surgery

Here’s a sobering statistic: The National Institute on Drug Abuse reports that roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them. Between 8 and 12 percent of those patients go on to develop an opioid-use disorder. From there, an estimated 4 to 6 percent of people who misuse prescription opioids transition to heroin.

It goes without saying that pain management is part of the post-procedure recovery process in aesthetic medicine, but many plastic surgery practices have been taking precautions and adjusting their approach to recovery in recent years as the opioid epidemic grows in the United States. “It's a cunning, baffling, powerful disease and it can happen to anyone,” says New York City-based dermatologist Cheryl Karcher, MD, who is open about her own battle with addiction several years ago. “I am much more on the lookout now.”

Because it can be difficult to identify who will become addicted and who won’t, providers — especially those in the already scrutinized fields of cosmetic and plastic surgery — have learned to take special care.

“Plastic surgery has never been more prevalent, more revered, and, at the same time, more scrutinized,” says board certified plastic surgeon, Ryan Neinstein, MD, of Neinstein Plastic Surgery in Manhattan. There are countless media stories of poor plastic surgery outcomes, he explains, and these are typically instances of procedures being performed by unqualified physicians in substandard facilities. “However, day in day out, plastic surgeons around the country are making surgery safer, faster, and more predictable,” he says.

Here, three experts share the precautions they’ve taken against opioid abuse in their own practices and how they’ve adjusted their approaches to the plastic surgery recovery process in recent years.

The Importance of Preoperative Counseling

Dr. Karcher says that she now asks a lot more questions about personal and family history of addiction when she meets with her patients. She routinely recommends Tylenol (acetaminophen) or Tylenol with ibuprofen (like Advil) for pain. New York City-based board certified facial plastic surgeon Jennifer Levine, MD, agrees that preoperative counseling is vital and lets her patients know that they may be uncomfortable, but the surgery is not especially painful. “Pain medication is available if they need it, but most patients do not require it,” she says. “Opiates are rarely necessary in my practice.”

Prescribing in Smaller Quantities

Dr. Karcher says that if the aforementioned Tylenol is not enough or if she knows a patient will really need pain medication to get to the point where they can recover properly, a few pain pills will be prescribed. That said, the tight leash on these dangerous drugs can lead to those who need pain management not getting the medication they need. “I do, unfortunately, see patients that have needed opiates for other medical or surgical issues and were not given them,” she says. “I do think opiates have a place in very short-term pain management.”

Responsible Discarding

For Dr. Levine, most of her procedures are above the neck and, as such, most of her patients do not require opioids. “I use a local anesthetic during the surgery and some longer-acting local anesthetics for longer procedures such as facelifts,” she says. The majority of her patients only take acetaminophen after the surgery. “I do give all my patients a small supply of a pain medication such as Vicodin (hydrocodone/acetaminophen),” she says, adding that she “rarely” prescribes anything stronger. “Many of my patients come in after the surgery with the bottle of unused pain medication and ask me to discard it for them.”

The Next Generation of Pain Management

One of the advances Dr. Neinstein has made to his practice is the use of a medication borrowed from the trauma world called tranexamic acid. The clotting promoter is used to treat heavy menstrual periods in women, and this low-cost drug can be added to the intravenous liquid given to a patient during surgery to aid the post-op recovery process. “This medication has quickly shown to safely contribute to minimizing blood loss,” he says. “Even in plastic surgery — where there is minimal blood loss — by reducing it even more we can further minimize the downtime and physiological change to our patients’ bodies.”