Published: March 31, 2020

Study Explores Ibuprofen Versus Opioid Therapy for Outpatient Post-Op Pain Control

In this Bulletin segment, our committee shares highlights from recent key publications in otolaryngology-head and neck surgery. We offer concise summaries of significant findings that may alter current surgical practice. The following original research is the focus for this issue.

Publication Spotlight: Highlights from OREBM

Uchechukwu Megwalu, MD, MPH, Joshua Bedwell, MD, Nikhila Raol, MD, MPH, and Vikas Mehta, MD, for Outcomes Research and Evidence-Based Medicine Committee

In this Bulletin segment, our committee shares highlights from recent key publications in otolaryngology-head and neck surgery. We offer concise summaries of significant findings that may alter current surgical practice. The following original research is the focus for this issue.


Prescription drug abuse is an epidemic in the United States, leading to over 60,000 deaths annually. Surgeons commonly prescribe opioid medications postoperatively for pain control. Diversion of unused prescribed opioid medications has been identified as a major contributor to the opioid epidemic. Furthermore, overprescribing of opioid medications can lead to chronic opioid dependence. In 2016, the Centers for Disease Control and Prevention issued guidelines for primary care physicians treating chronic pain with opioids. Unfortunately, there is a paucity of opioid-prescribing guidelines for postoperative pain control. Consequently, there is a wide variety of opioid-prescribing practices among surgeons. Nonopioid analgesics represent a possible alternative to opioid medications. However, it is unclear if they are as effective in controlling postoperative pain in patients undergoing otolaryngologic surgery. This single-blind randomized control study examined the efficacy of primary analgesic therapy with ibuprofen versus opioid medication in patients undergoing outpatient otolaryngologic surgery.

The study participants included adult patients undergoing outpatient otolaryngology surgery at a tertiary care academic hospital. The surgical procedures included thyroidectomy, parathyroidectomy, functional endoscopic sinus surgery (FESS), septoplasty, septorhinoplasty, tympanoplasty, and endolaryngeal procedures requiring general anesthesia and microsuspension direct laryngoscopy. Tonsillectomy was excluded. All patients received a prescription for hydrocodone/acetaminophen (APAP) (5 mg / 325 mg) and ibuprofen (600 mg) to be used every six hours as needed for pain. Primary analgesic therapy was defined as the first medication that patients were assigned to take for pain control, and secondary therapy was defined as the backup medication to be used when primary therapy provided inadequate analgesia. Patients were randomly assigned to take either the opioid medication (opioid group) or ibuprofen (ibuprofen group) as the primary analgesic therapy. The attending surgeon was blinded to the patient’s assigned treatment group, but patients were not blinded. The primary outcome measure was opioid consumption, and the secondary outcome measure was the patient-reported pain score.

A total of 185 patients were randomized, 97 patients in the opioid arm, and 88 patients in the ibuprofen arm. Of these, 108 (58 percent) completed the study: 56 patients in the opioid arm and 52 patients in the ibuprofen arm. Patient characteristics were similar between groups. The opioid consumption rate was higher in the opioid group compared with the ibuprofen group. The mean number of opioid pills taken was 4.9 (95% confidence intervals [CI] 3.6 to 6.1) for the opioid group versus 2.0 (95% CI 0.9 to 3.1) for the ibuprofen group. Those in the opioid group also required more doses of their secondary medication. There was no difference in reported pain scores between the treatment groups. No major complications were noted in either group. No patient reported hematoma or bleeding that required intervention.

The findings of this study suggest that the use of ibuprofen as primary analgesic therapy provides equally effective pain control as hydrocodone/APAP in patients undergoing a wide variety of outpatient otolaryngology surgical procedures. Furthermore, this strategy decreases overall opioid requirement. The authors also noted that many more patients assigned to the opioid group took their secondary medication than patients in the ibuprofen group, suggesting with this self-crossover design that ibuprofen may be superior in controlling postoperative pain. Finally, and of particular interest given the concerns about diversion, the patients were prescribed 20-30 pills of opioids in each treatment arm and the vast majority used very few of these pills regardless of the primary pain regimen and surgical procedure.

This study was limited by significant loss of participants to follow up. Additionally, while the power analysis indicates adequate sample size to detect differences in pain scores between groups when all surgical procedures were combined, it is unclear if the sample size was adequate for analyses by procedure. Finally, the authors did not control for medications used in the perioperative setting. Thus, the findings need to be interpreted in light of these limitations. Overall, the results of the study highlight that opioids are often overprescribed after routine otolaryngology procedures and that the use of ibuprofen as a primary means of controlling pain is a safe and potentially more effective method than opioids.

Nguyen KK, Liu YF, Chang C, Park JJ, Kim CH, Hondorp B, Vuong C, Xu H, Crawley BK, Simental AA, Church CA, Inman JC. A randomized single-blinded trial of ibuprofen- versus opioid-based primary analgesic therapy in outpatient otolaryngology surgery. Otolaryngology Head Neck Surg. 2019 May;160(5):839-846.

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