Incidence and Predictive Factors for Additional Opioid Prescription after Endoscopic Skull-Base Surgery

Introduction: Postoperative pain management and opioid use following endoscopic skull base surgery (ESBS) is not well understood. A subset of patients requires additional opioid prescription (AOP) in the postoperative period. The objective of this study is to describe the incidence of AOP as well as evaluate patient and surgical characteristics that may be predictive additional pain management requirements following ESBS.

Methods: A retrospective review of subjects undergoing ESBS between November 2016 and August 2018 was performed. The medical and Controlled Substance Utilization Review and Evaluation System (CURES) records were reviewed. Sociodemographic and clinical characteristics including age, sex, ethnicity, marital status, employment, insurance, median income, distance to provider, psychiatric comorbidities, tobacco and alcohol use, and perioperative factors were included in our analysis. Stepwise multivariable logistic regressions were performed to evaluate the factors associated with AOP within 60 days following surgery.

Results: A total of 42 patients were identified (28 anterior skull base, 6 middle cranial fossa, 5 sinonasal malignancy, and 3 cerebrospinal fluid leak repair procedures). Additional opioid prescriptions were recorded in 9 patients (21.4%). There were no significant differences in perioperative surgical factors (ASA score, dexamethasone, or acetaminophen use) between single-prescription and AOP cohorts. On multivariable logistic regression, preoperative opioid use (odds ratio [OR]: 19.4; 95% CI: 2.7–135.2), comorbid depression (OR: 8.0; 95% CI: 1.4–47.0), and lower age (β= 0.90; 95% CI: 0.82–0.99) were associated with the need for additional prescriptions postoperatively (p < 0.05).

Conclusion: The requirement for extended postoperative opioid pain control is common after ESBS, as a subset of patient are not controlled with discharge medications exclusively. Patient demographics including age and psychosocial factors such as depression may predict the need for AOP after ESBS. These results reflect similar findings in pain management following endoscopic sinus surgery, which suggest that patient-driven, rather than surgical, factors may determine the need for prolonged pain control requirements after ESBS.