What Otolaryngologists Should Consider When Prescribing Opioids

In keeping with the goal of balancing beneficence with nonmaleficence, the otolaryngologist should pre-emptively assess the patient’s mental capacity and capability, while also evaluating the risk stratification for serious side effects of opioids such as mental disorientation, falls, accidents, and accidental overdose. While shared decision making in patient care is often the norm, in the case of opioid prescribing, there are overriding legal, professional, and ethical considerations that limit the ability of the otolaryngologist to approve the inappropriate and potentially dangerous prescribing of narcotics when not clinically indicated. Here, the otolaryngologist has a higher responsibility to patient safety and well being that may require refusing the patient’s request for more opioid prescribing. The otolaryngologist must often make hard decisions regarding patient requests for narcotic-level pain medications beyond the period of reasonable need. Alternatives such as NSAIDS (if tolerated), massage therapy, physical therapy, other non-narcotic pain medications, biofeedback, and referral to a pain specialist are all potential options. Coordinating pain medications and pain control with the patient’s primary care physician is also a very important responsibility. In the situation of chronic pain in a patient, the otolaryngologist has many resources for assistance in pain management so that full responsibility is not necessarily required.

Other resources for the otolaryngologist can be “best practices,” and “standards of care,” guidelines that are available from many sources, including the Centers for Disease Control and Prevention’s “Guidelines for Prescribing Opioids for Chronic Pain” (MMWR Recomm Rep. 2016;65:1–49). The prescribing of opioids in pediatric patients is undergoing re-evaluation and change, based on new information that there is a risk for significant complications in some patients undergoing tonsillectomy or tonsillectomy-adenoidectomy, especially those with obstructive sleep apnea. Additionally, some children who are rapid metabolizers of codeine to morphine in the liver are at high risk for respiratory depression and death. The alternative use of acetaminophen/ibuprophen is a recommendation that is still under investigation, particularly with respect to a possible increased risk of postoperative hemorrhage. The concerned otolaryngologist has an ethical and professional responsibility to stay informed on current outcomes research and recommended guidelines for pain management in both adult and pediatric patients.

Individualize Your Approach

In consideration of the two patient cases, and with reference to the ethical perspectives noted above, the otolaryngologist will need to individualize the approach to pain management for each patient, as the pain etiologies are different and, therefore, management may not be similar. In general, chronic pain from cancer or cancer treatments is special and is not necessarily approached in the same way as post-trauma pain in developing and maintaining a pain management plan. Cancer pain can arise due to both recurrence/metastasis of the tumor and the resulting treatment (chemoradiation, surgery). Typically, the management of head and neck cancer is a team effort, and it is very common for the otolaryngologist to have access to consultations with a pain specialist who understands the pain associated with cancers in this region. Multi-modality therapy is often recommended—and needed—for cancer-related pain, and such consultations are generally quite beneficial to both the patient and the otolaryngologist. Additionally, discussing pain management goals with the patient’s primary care physician can be quite helpful and appropriate.