In Reply Sun and colleagues raise important points regarding primary hemorrhage, surgical technique, and nonopioid analgesics. Our decision to not examine primary hemorrhage in our study1 was driven by 2 considerations. First, primary hemorrhage occurs within 24 hours of surgery (eg, on the day of surgery or the day after). Therefore, any putative effect of perioperative opioid prescribing on the risk of primary hemorrhage (eg, by reducing the use of nonsteroidal anti-inflammatory drugs [NSAIDs]) would have to be strong and immediate. However, prior studies do not suggest that the association between NSAID use and hemorrhage is large, if it exists at all.2-5 Given the lack of a reasonable a priori mechanism between perioperative opioid prescribing and primary hemorrhage, any detected association would most likely be incidental or due to confounding. Second, our definition of perioperative opioid prescription included opioid prescriptions filled from a week before surgery to 1 day after surgery. To establish a clear temporal relationship between perioperative opioid prescriptions and primary hemorrhage, we would have needed to exclude prescriptions filled the day after surgery while only analyzing primary hemorrhages that occurred on the day after surgery.
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Chua K, Harbaugh CM, Brenner MJ. Opioid Prescriptions and Risk of Complications After Tonsillectomy in Children. JAMA Otolaryngol Head Neck Surg. Published online November 14, 2019. doi:https://doi.org/10.1001/jamaoto.2019.3432
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