Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

INTRODUCTION

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

AREAS COVERED

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

EXPERT OPINION

The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.

The Role of Liposomal Bupivacaine in Multimodal Pain Management Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Faster and Farther With Less Opioids

STUDY DESIGN

Retrospective controlled cohort.

OBJECTIVE

To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on postsurgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS).

SUMMARY OF BACKGROUND DATA

Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied.

METHODS

119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed.

RESULTS

Group A experienced significantly lower total opioid consumption compared to Group B (44.5 mg vs. 70.2 mg). Morphine use was lower in Group A on postoperative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting.

CONCLUSIONS

LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period.

LEVEL OF EVIDENCE

3.

Short-acting versus long-acting opioids for pediatric postoperative pain management

INTRODUCTION

Opioids are potent analgesics commonly used to manage children's moderate to severe perioperative pain in children. A wide range of short and long-acting opioids are used to treat surgical pain and will be reviewed in this article.

AREAS COVERED

Both short- and long-acting opioids contain unique therapeutic benefits and adverse effects; however, due to the side effect profile and safety concerns, lack of familiarity, and evidence with long-acting opioids to treat surgical pain, shorter-acting opioids have traditionally been used in children. Almost all opioids work by binding to the mu receptor. Methadone, a long-acting opioid, is an exception because it also has beneficial N-methyl-D-aspartate antagonist properties. Clinically methadone's properties could translate to improved analgesic outcomes, reduced risk of adverse events, less risk for acute hyperalgesia, tolerance and abuse potential, faster recovery, and reduced risk for chronic persistent surgical pain. This review article summarizes and compares the evidence of commonly used short and long-acting opioids for perioperative pain control in the pediatric population.

EXPERT OPINION

Individualized methadone therapy using pharmacogenomics has the potential to transform opioid use in pain management by improving patient safety and analgesic outcomes, thereby addressing the gaps in current standardized ERAS protocols.

Prospective analysis of home narcotic consumption and management of excess narcotic prescription following adolescent idiopathic scoliosis surgery

PURPOSE

The aim of this study was to identify factors associated with the outpatient narcotic intake of patients following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to introduce a safe and effective method of disposing of unused narcotics.

METHODS

Following Institutional Review Board approval, retrospective review of prospectively collected data from patients undergoing PSF for AIS took place. Pain scores, narcotic use, patient demographic data, pre-, intra-, and postoperative parameters, and discharge data were gathered via chart review. Patients were divided into two groups according to home narcotic use, high use (top 25th percentiles) and low use (bottom 75th percentiles), and multivariate statistical analysis was conducted. Narcotic surplus was collected during postoperative clinic visits and disposed of using biodegradable bags.

RESULTS

Statistical analysis of 27 patients included in the study showed that patients with a higher home narcotic use correlated with increased length of hospitalization with an average of 3.4 days compared to the lower-use group of 2.8 day (p = 0.03). Higher-use group also showed increased inpatient morphine milligram equivalent than the lower-use group. There was no significant difference of home narcotic use when looking at patient age, height, weight, BMI, levels fused, intraoperative blood loss, or length of surgery. A total of 502 narcotic doses were disposed of in the clinic.

CONCLUSION

Our study suggests that there are not a significant number of patient- or surgical-level factors predisposing patients to increased home narcotic usage following spinal fusion for adolescent idiopathic scoliosis.

LEVEL OF EVIDENCE

Level I, prospective study.

Perioperative Indications for Gabapentinoids in Pediatrics: A Narrative Review

In recent years, there has been increased interest in using gabapentinoids (gabapentin and pregabalin) as part of multimodal medication plans or enhanced recovery after surgery protocols to mitigate several perioperative clinical challenges. Outcomes explored in the context of using gabapentinoids perioperatively in children are variable and include acute complications of pain, anxiety, nausea and vomiting, and emergence agitation, as well as the long-term postoperative outcome of chronic postsurgical pain. This narrative review describes the current literature regarding perioperative use of gabapentinoids in pediatric patients and aims to describe the role of gabapentinoids in the perioperative setting for each specific indication.

Pilot implementation of opioid stewardship measures using the national surgical quality improvement program-pediatric platform

INTRODUCTION

Data surrounding optimal pediatric postoperative opioid prescribing are incomplete. The objective of this study was to leverage the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-P) and assess feasibility of added data collection surrounding pediatric perioperative pain management practices including opioid prescribing at discharge.

METHODS

Nineteen (19) novel data elements were added to NSQIP-P data collection of selected patients, ages 5-18 years, who had undergone surgery at a single, free-standing children's hospital. Metrics around data abstraction and completion of variables were collected. Univariate analyses (using Chi-square or Wilcoxon Rank Sum tests) and multiple logistic regressions were performed to describe predictors of opioid prescribing at discharge and to monitor adherence to Food and Drug Administration (FDA) prescribing recommendations.

RESULTS

Median abstraction time of the novel variables decreased from 12 to 5 min per patient over 13 months with 94% variable completion rate. Of 878 patients, 302 (36.4%) were prescribed opioids at discharge. Factors associated with an opioid prescription included older age (p < 0.001), white race (p < 0.05), undergoing an orthopedic surgery (p < 0.001), and receiving a regional block perioperatively (p < 0.001). All opioid prescriptions met FDA guidelines with no patients receiving codeine, and 98% of patients receiving opioid prescriptions < 50 morphine milli-equivalents per day.

CONCLUSION

Collecting data on current pain management practices, opioid prescribing, and adherence to safety recommendations is feasible using the NSQIP-P with little added burden. Further expansion of data collection is needed to develop generalizable optimal prescribing practices for post-discharge pain management for children.

Effect of narcotic prescription limiting legislation on opioid utilization following pediatric spinal fusion for scoliosis

BACKGROUND CONTEXT

Since 2016, 35 of 50 US states have approved opioid-limiting and monitoring laws. The impact on postoperative opioid prescribing and secondary outcomes following pediatric scoliosis deformity correction surgery remains unknown.

PURPOSE

To evaluate the effect of CURES 2.0 opioid-limiting regulations on postoperative opioid prescriptions and unplanned readmissions following pediatric scoliosis deformity correction surgery.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Two patient cohorts (pre-CURES January 1, 2017-October 22, 2018 and post-CURES September 1, 2018-May 30, 2020) that included all patients undergoing pediatric scoliosis deformity surgery at a single institution.

METHODS

Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) prescribed was compared at 30-day postoperative intervals. Readmission rates were calculated. Categorical variables were evaluated with Chi squared analysis and continuous variables were evaluated with t test or Mann-Whitney U test as appropriate. Logistic regression was used to evaluate risk factors for increased postoperative opioid.

RESULTS

Of 108 identified patients, 94 (49 pre-CURES, 45 post-CURES) were included in the study. Post-CURES patients were older (p = 0.001). All other demographic, medical, and surgical factors were similar between pre-CURES and post-CURES patients (all p > 0.05). Post-CURES, patients received fewer pills in their first postoperative prescription (43.4 vs. 57.4 pills, p = 0.006), less opioids (MMEs) during the first 0 to 30-day and 31 to 60-day postoperative intervals (261.8 MMEs vs. 337.6 MMEs, p = 0.028 and 17.8 MMEs vs. 59.7 MMEs, p = 0.016, respectively). Increased 120-day opioid utilization was associated with surgery in the pre-CURES period, age, BMI, and decreased number of levels fused (all p < 0.05). Postoperative readmission within 90 days was associated with age, BMI, number of levels fused, and length of stay.

CONCLUSIONS

Implementation of CURES 2.0 has resulted in a reduction in the opioid prescription following pediatric scoliosis deformity surgery without an increase in readmissions. Further studies are needed to evaluate how legislations of this kind affect patient reported outcomes, satisfaction, and quality of life.