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Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus Jessica M. Donigan, MD, a Divya Srivastava, MD, b Ian Maher, MD, c Mark Abdelmalek, MD, d Anna A. Bar, MD, e Travis W. Blalock, MD, f Jeremy S. Bordeaux, MD, MPH, g David G. Brodland, MD, hij Bryan T. Carroll, MD, PhD, g MARTHA Laurin Council, MD, k Keith Duffy, MD, a Ramin Fathi, MD, l Nicholas Golda, MD, m Hillary Johnson-Jahangir, MD, PhD, MHCDS, n Sailesh Konda, MD, o Justin J. Leitenberger, MD, e Molly Moye, MD, p Jenny L. Nelson, MD, q Vishal A. Patel, MD, r Joseph J. Shaffer, MD, s Razieh Soltani-Arabshahi, MD, t Payam Tristani-Firouzi, MD, u Amanda J. Tschetter, MD, v and Rajiv I. Nijhawan, MD b Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 04/05/2024 BACKGROUND Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence. OBJECTIVE To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction. METHODS This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at $ 80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval. RESULTS Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid. CONCLUSION Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommen dations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic. O pioid abuse is an epidemic in the United States, and mortality from opioid overdoses continues to in crease. 1,2 Unfortunately, physicians play a role, as

Previous studies have found that pain following Mohs micrographic surgery (MMS) tends to be mild to moderate, peaking within the first 36 hours after surgery. 5 – 9 Predictors of postoperative pain include lip, ear, scalp, genital, and lower extremity sites; increased number of stages; closure with flaps and grafts; patient anxiety about pain; female gender; and age younger than 66 years. 5 – 8,10 – 12 Many patients do not take pain medication after MMS or only require 1 to 2 doses, 5,6,8 which can result in excess medication available for misuse. 10

40% of overdoses involve prescription opioids. 3 Although lower than the national rate for all health care providers, Mohs surgeons provide opioid prescriptions 8.4 times more than general dermatologists. 4 Therefore, Mohs surgeons should be cognizant of their opioid prescribing practices because overprescribing may contribute to the epidemic.

Fromthe a Department of Dermatology, University of Utah, Salt Lake City, Utah; b Department of Dermatology, University of Texas Southwestern, Dallas, Texas; c Department of Dermatology, University of Minnesota, Minneapolis, Minnesota; d Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; e Department of Dermatology, Oregon Health and Science University, Portland, Oregon; f Department of Dermatology, Emory University, Atlanta, Georgia; g Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio; h Zitelli & Brodland, P.C. Skin Cancer Center, Pittsburgh, Pennsylvania; i Zitelli & Brodland, P.C. Skin Cancer Center, Clairton, Pennsylvania; j Departments of Dermatology, Otolaryngology, and Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; k Division of Dermatology, Washington University School of Medicine in St. Louis, St. Louis, Missouri; l Phoenix Surgical Dermatology Group, LLC, Phoenix, Arizona; m Department of Dermatology, University of Missouri, Columbia, Missouri; n Department of Dermatology, University of Iowa, Iowa City, Iowa; o Department of Dermatology, University of Florida, Gainesville, Florida; p Forefront Dermatology, Louisville, Kentucky; q Avera Medical Group Dermatology Sioux Falls, Sioux Falls, South Dakota; r Department of Dermatology, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia; s Dermatology Consultants, St. Paul, Minnesota; t Department of Dermatology, University of Southern California Keck School of Medicine, Los Angeles, California; u Revere Health, Provo, Utah; and v Dermatology Specialists, Edina, Minnesota The authors have indicated no significant interest with commercial supporters. Address correspondence and reprint requests to: Jessica M. Donigan, MD, 30 North 1900 East, 4A330 School of Medicine, Salt Lake City, UT 84132, or e-mail: jessica.donigan@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the

journal ’ s Web site (www.dermatologicsurgery.org). http://dx.doi.org/10.1097/DSS.0000000000002551

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