Apples to oranges: How hemorrhoidectomy pain control differs from other anorectal procedures

Abstract

Background: Over- prescription of opioids after surgery contributes to the national opioid epidemic. Differences may exist with procedure type, but these are understudied. Objective: This study aims to evaluate opioid consumption patterns following hemorrhoidectomy vs. other anorectal operations, as hemorrhoidectomy recovery is reportedly more painful. Design: Retrospective cohort study with prospective telephone survey. Setting: Single safety net hospital. Patients: Group of 27 and 73 patients undergoing outpatient hemorrhoidectomy and anorectal surgery other than hemorrhoidectomy, respectively, between July 2019 and March 2020. Main Outcome Measures: We measured the prescription and consumption quantities of morphine milligram equivalents (MME) after surgery for hemorrhoids vs. other anorectal procedures. Results: MME prescribed at discharge was higher for the hemorrhoid cohort vs. for other anorectal surgery (86.1 ± 17.5 vs. 76.0 ± 6.3, P < 0.001). The hemorrhoid group utilized higher quantities of MME during recovery: 30 (IQR 75 MME) vs. 6.25 (IQR 30 MME), P = 0.017), and also expressed lower satisfaction with their post-operative pain control regimen (33.3% vs. 88.3%, P < 0.001). No differences were seen in patients continuing on opioids on postoperative day seven (p = 0.348), and patients with complete compliance with their non-opioid multimodal pain control regimen (p = 1.0). Return trips to the emergency department for pain and patients requiring additional opioid medication after discharge were higher in the hemorrhoidectomy group (33.3% vs. 1.3%, P < 0.001 and 14.8% vs. 1.3% P = 0.016, respectively). The 50th, 75th, and 90th percentile for total MME consumed by the hemorrhoidectomy (vs. other anorectal surgery) cohort were 75 (vs. 30), 75 (vs. 54), and 97.5 (vs. 75) MME, respectively. Conclusions: Hemorrhoidectomy surgery requires up to five times the amount of opioids for postoperative pain control compared to other anorectal surgeries. Prescribed opioids still exceed the amount used, although dissatisfaction with pain control remains high after hemorrhoid surgery. Further study is required to better understand this unique entity. Limitations: Retrospective single-center design, patient-reported outcomes, male majority in the non-hemorrhoidectomy group. Conflict of Interest: None.