Shannon T. Nugent, MD

Credit: UPenn.edu

Patients’ perception of risk of becoming addicted to opioids affects their choice of pain medications following Mohs micrographic surgery (MMS), according to recent findings.¹

These findings were the result of a discrete choice experiment study into the decisions of patients undergoing Mohs surgery, given that among US patients, around 26% who had Mohs surgery from January of 2009 to June of 2020 filled a prescription for an opioid.²

This research was authored by Shannon T. Nugent, MD, from Sidney Kimmel Medical College at Thomas Jefferson University in Pennsylvania.

“The purpose of this study was to investigate patient preferences for pain medications after MMS using a discrete choice experiment (DCE),” Nugent and colleagues wrote. "This study evaluated how patients weighed the potential benefit of improved pain control vs the risk of long-term opioid addiction to determine when opioids plus over-the-counter pain medications (OTCs) are preferred to only OTCs for pain management after MMS.”

Background and Findings

The investigators conducted a prospective study and recruited participants who were undergoing MMS. Their accompanying support persons (1 per participant) were recruited between August of 2021 and April of 2022 to participate in the patients’ completion of a survey.

The research team’s survey was administered once in the clinic waiting area, regardless of the timing of the visit. Prior to data collection, the survey was pilot-tested and reviewed with multiple stakeholders.

For the team to establish a baseline understanding of adverse effects related to pain medication, the participants were told to rate the importance of limiting these effects. The main part of the survey utilized discrete choice experiments (DCE) to assess preferences for pain control after MMS.

Participants were presented with 12 scenarios, each of which involved a choice between 2 hypothetical pain management options: "opioids + OTC" or "OTC only." The scenarios varied in pain levels and risk of addiction profiles, with different attributes and levels based on literature review. The investigators’ DCE scenarios were presented in random order.

The investigators’ study was done to determine respondents' overall preferences for pain control after MMS by evaluating how they weighed the potential benefits of improved pain control against the risk of opioid addiction. The primary outcome, median risk equivalence, was measured through the use of conjoint analysis and through linear interpolation between discrete attribute level parameters. The study estimated a minimum sample size of 250 respondents to achieve reliable results.

Among the 295 total respondents who completed the team’s study, a major portion expressed their reluctance towards using opioids for the purposes of pain management. Around 34% added that they would never consider using opioids, regardless of the pain level they experienced.

Additionally, the investigators reported that 50% of the respondents showed concerns about potential opioid addiction. Out of all the scenarios which were presented, the investigators found that the majority of the respondents (76%) preferred using only OTC medications for pain control after the surgery.

Even when the theoretical risk of addiction was low (at 0%), the team noted that half of the respondents still preferred OTCs plus opioids when the pain level reached around 6.5 on a 10-point scale.

However, as the risk of opioid addiction increased—2%, 6%, and 12%—an equal preference between OTCs plus opioids and only OTCs was not observed. In these scenarios, the investigators noted, despite experiencing high levels of pain, the patients still favored the use of only OTCs for pain control.

“Our study population included a high percentage of health care workers and individuals with relatively high education and household income,” they added. “Therefore, the findings of this study may not be generalizable to the larger population.”

References

1. ^{Nugent ST, Veerabagu SA, Madden M, et al. Patient Preferences for Pain Control After Mohs Micrographic Surgery: A Single-Center Discrete Choice Experiment. JAMA Dermatol. Published online July 05, 2023. doi:10.1001/jamadermatol.2023.1899.}
2. ^{Veerabagu SA, Cheng B, Wang S, et al. Rates of opioid prescriptions obtained after Mohs surgery: a claims database analysis from 2009 to 2020. JAMA Dermatol. 2021;157(11):1299-1305. doi:10.1001/jamadermatol.2021.3468.}