Decreasing postoperative opioid use while managing pain: A prospective study of men who underwent scrotal surgery

Abstract Objective To compare postoperative pain control among men who received different quantities of narcotic prescriptions following scrotal surgery. We hypothesized that men receiving eight vs four pills of acetaminophen 300 mg/codeine 30 mg there would be no significant difference in mean pain following scrotal and inguinal surgery. Patients and methods In this prospective, open‐label study, men who underwent scrotal surgery received eight or four acetaminophen 300 mg/codeine 30 mg pills. Men were encouraged to take scheduled non‐steroidal anti‐inflammatory drugs (NSAIDs), apply ice on the incision, and take acetaminophen 300 mg/codeine 30 mg as needed for breakthrough pain. Men were evaluated within 1‐2 weeks after surgery. Statistical analysis was performed using Microsoft Excel and Stata/IC 15.1. Results A total of eighty‐seven men met inclusion criteria, fifty‐four men received eight acetaminophen/codeine pills, and thirty‐three men received four pills. There was no significant difference in mean pain score (0‐10) of men receiving eight pills vs four pills in the week after surgery (3.6 ± 1.9 vs 3.3 ± 1.8, P = .5004). Of men who used NSAIDs and ice, 93.5% and 92.3% found them to be moderately or very helpful. Conclusion Reducing the total prescription of combined narcotic/non‐narcotic medication is not associated with increased postoperative pain in patients undergoing scrotal/inguinal surgery. There was no difference in postoperative pain in men taking eight or four acetaminophen 300 mg/codeine 30 mg pills. A limited prescription of eight or four pills was adequate for pain control in the majority of men who underwent scrotal surgery. NSAIDs and ice were found to be useful adjuncts for pain relief by those who used them.


| PATIENTS AND ME THODS
In this institutional review board approved study, informed consent was obtained from study participants. We create a prospective database of men undergoing scrotal and inguinal urological procedures from September 2018 to September 2019 associated with specified current procedural terminology codes: sub-inguinal varicocelectomy, vasovasostomy, vasoepididymostomy, testes biopsy, microepididymal sperm aspiration, microdissection testicular sperm extraction, scrotal orchiectomy, and hydrocele. In addition to general anesthesia, all men received local anesthesia with 10cc of 1% lidocaine at the end of the procedure. Men were instructed to take non-steroidal anti-inflammatory drugs (NSAIDs) every 4-6 hours, apply ice packs to the incision for 24 hours after surgery, and take 1-2 pills of acetaminophen 300 mg/codeine 30 mg as needed for breakthrough pain.
Initially all men were prescribed eight acetaminophen 300 mg/codeine 30 mg pills, starting at the study's chronological mid-point (April 2019) the number of pills prescribed was reduced four. This study was open-label, both participants and clinicians had access to the dose and quantity of prescribed medications.
At the first follow-up visit, typically within 2 weeks after surgery, the men were asked to recall their mean pain on a scale of 0-10 with 10 being the worst, the number of narcotic pills taken, whether NSAIDs and ice were used, and the efficacy of the ice and NSAIDs in pain control during the first week post-surgery. Efficacy was measured using a 4-point questionnaire as "very helpful," "moderately helpful," "minimally helpful," and "not used". We attempted to contact men who did not appear at the follow up-visit via telephone. Men were asked to bring remaining medication to the follow-up visit for verification or count the remaining pills when contacted by phone.
The only exclusion criteria were those who had pre-existing opioid prescriptions or underwent more than one surgery. A combination of Microsoft Excel and Stata/IC 15.1 was used to organize data and perform statistical analysis. One-way ANOVAs and independent ttests were computed to analyze whether the amount of pain or pill consumption varied by age, procedure, and compare levels of pain by number of pills taken. Chi-squared test were performed to analyze the helpfulness of ice and NSAIDs reported by different groups.
Pearson correlations were calculated to examine the degree to which pain and pill consumption correlated. Post-hoc power calculations were conducted using the freely available ClinCalc post-hoc power calculator (http://clinc alc.com/stats /Power.aspx).

| RE SULTS
A total of 127 men underwent scrotal and inguinal surgery. Of those patients, 87 men met inclusion criteria, 2 were excluded due to pre-existing opioid prescriptions, 2 was excluded due to multiple procedures, and 36 were excluded due to lost to follow-up. The number of patients lost to follow-up was similar in both groups. Of the men who met inclusion criteria, 54 men received eight acetaminophen/codeine pills and 33 received four pills. The mean age was 36.8 ± 9.9 years ( Table 1). The overall reported mean pain (0-10) was 3.5 ± 1.9 in the week after surgery, and 3.6 ± 1.9 vs 3.3 ± 1.8 (P = .5004) for men receiving eight vs four acetaminophen/codeine pills, respectively ( Table 2). Men who received eight pills took a mean of 4.2 ± 3.0 and kept 3.5 ± 3.0 pills ( Table 2). There were no phone calls to the provider requesting re-fills in either group, TA B L E 1 Characteristics of men undergoing scrotal and inguinal surgery during the study period  Ice and NSAIDs are useful adjuncts for pain control for most men, 89.7% and 93.5% of those who used them found ice and NSAIDs to be moderately to very helpful. The rates of ice and NSAID use and reported efficacy were similar between the two cohorts (Table 3).

| D ISCUSS I ON
Interestingly, four-pill cohort reported greater satisfaction with ice than the eight-pill cohort (84.8% found ice to be very helpful vs In light of these studies and our own results, we believe a reasonable next step would be to attempt narcotic-free postoperative management of men who have undergone scrotal and inguinal surgery. There was no statistically significant difference in pain reported by those receiving eight vs four acetaminophen/codeine pills, and both groups took approximately half the pills prescribed on mean (4.2 ± 3.0 vs 2.1. ± 1.8). In our study, many more men took acetaminophen/codeine (78.1%) than NSAIDs (35.6%), despite the high efficacy reported by those who took NSAIDs (93.5%). A possible explanation is that some patients who took all the opioid pills believed that they were following physician orders to take them all. Another possible explanation is that anticipation of pain prompted men to take the medication perceived to be stronger. The low overall use of NSAIDs   (6)