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were excluded to limit inaccurate recommendations for scenarios in which an opioid prescription may or may not be appropriate. Additional consensus studies with a larger number of panelists may provide additional guidance. Although this study aimed to identify scenarios in which an opioid prescription should, or should not, be routinely prescribed after MMS and reconstruction, consensus was only met for situations in which opioids should not routinely be prescribed, highlighting that there is no scenario in which an opioid prescription is always indicated. Increasing awareness of this fact is critical in decreasing unnecessary opioid prescriptions and limiting any potential negative contribution that dermatologic surgery, as a specialty, may have on the opioid epidemic. References 1. Volkow ND. Prescription Opioid and Heroin Abuse . 2014. Available at: https://www.drugabuse.gov/about-nida/legislative-activities/testi mony-to-congress/2016/prescription-opioid-heroin-abuse#2. Accessed August 2, 2017. 2. Scholl L, Seth P, Kariisa M, Wilson N, et al. Drug and opioid-involved overdose deaths — United States, 2013-2017. MMWR-Morbidity Mortality Weekly Rep 2019;67:1419 – 27. 3. Seth P, Rudd RA, Noonan RK, Haegerich TM. Quantifying the epi demic of prescription opioid overdose deaths. Am J Public Health 2018;108:500 – 2. 4. Feng H, Kakpovbia E, Petriceks AP, Feng PW, et al. Characteristics of opioid prescriptions by Mohs surgeons in the medicare population. Dermatol Surg 2020;46:335 – 40. 5. Sniezek PJ, Brodland DG, Zitelli JA. A randomized controlled trial comparing acetaminophen, acetaminophen and ibuprofen, and acet aminophen and codeine for postoperative pain relief after Mohs sur gery and cutaneous reconstruction. Dermatol Surg 2011;37:1007 – 13. 6. Chen AF, Landy DC, Kumetz E, Smith G, et al. Prediction of post operative pain after Mohs micrographic surgery with 2 validated pain anxiety scales. Dermatol Surg 2015;41:40 – 7. 7. Limthongkul B, Samie F, Humphreys TR. Assessment of postoperative pain after Mohs micrographic surgery. Dermatol Surg 2013;39: 857 – 63. 8. Firoz BF, Goldberg LH, Arnon O, Mamelak AJ. An analysis of pain and analgesia after Mohs micrographic surgery. J Am Acad Dermatol 2010;63:79 – 86. 9. Saco M, Golda N. Optimal timing of post-operative pharmacologic pain control in Mohs micrographic surgery: a prospective cohort study. J Am Acad Dermatol 2020;82:495 – 97. 10. Harris K, Curtis J, Larsen B, Calder S, et al. Opioid pain medication use after dermatologic surgery A prospective observational study of 212 dermatologic surgery patients. Jama Dermatol 2013;149:317 – 21. 11. Merritt BG, Lee NY, Brodland DG, Zitelli JA, et al. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol 2012;67:1302 – 9. 12. Donigan JM, Franco AI, Stoddard GJ, Hedderman A, et al. Opioid prescribing patterns after micrographic surgery: a follow-up retro spective chart review. Dermatol Surg 2019;45:508 – 13. 13. Helmer O. Analysis of the Future: the Delphi Method . RANDCor poration; 1967. Available at: https://www.rand.org/pubs/papers/ P3558.html. Accessed September 16, 2019. 14. Chang AK, Bijur PE, Esses D, Barnaby DP, et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA 2017;318: 1661 – 7. 15. St Charles CS, Matt BH, Hamilton MM, Katz BP. A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillec tomy patient. Otolaryngol Head Neck Surg 1997;117:76 – 82.

TABLE 1. Characteristics of Delphi Panelists Panelist Characteristic Mean age, yr (range)

41 (33 – 59)

Male, n (%)

14 (60.9)

Mean time in practice, y (range)

8.3 (0.5 – 28.0)

Practice type, n (%) Academic

13 (56.5) 9 (39.1)

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Private

Both

1 (4.3)

Practice setting, n (%) Urban

11 (47.8) 4 (17.4) 5 (21.7)

Urban/suburban

Suburban

Suburban/rural

1 (4.3) 2 (8.7)

Rural

Practice region, n (%) West

6 (26.1) 8 (34.8) 6 (26.1) 3 (13.0)

Midwest

South

Northeast

Mode of opioid prescribing, n (%) Written required

11 (47.8) 7 (30.4) 10 (43.5)

Electronic

Phone*

Call requirements, n (%) Take call

23 (100)

First call

10 (43.4%)

* Only acetaminophen/codeine and tramadol can be prescribed over the phone by these providers.

defects requiring complex repairs. Although certain situations may warrant an opioid prescription, these medications should not routinely be prescribed as a matter of convenience for either the patient or the physician. Careful consideration should be given prior to providing a prescription because patients are more likely to take an opioid when it has been prescribed even if their pain may have been adequately managed without opioids. 7 Studies have shown that ibuprofen 6 acetaminophen is as effective as opioids in controlling postoperative pain with fewer complications. 5,14,15 The current study is not without limitations. Because this was a questionnaire-based study, it relies on the assumption that the panelists ’ answers reflect their actual prescribing habits. The exclusion of surgeons who always provide an opioid prescription may be another potential source of bias and possibly deterred some surgeons from participating. Because the goal of this study was to create consensus recommendations for potential scenarios in which an opioid prescription may or may not be warranted, surgeons who provide all patients a prescription as a standard practice

Opioid Prescribing Recommendations • Donigan et al

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