Pediatric surgeon opioid prescribing behavior: A survey of the American Pediatric Surgery Association membership

Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US

Importance

High-risk infants, defined as newborns with substantial neonatal-perinatal morbidities, often undergo multiple procedures and require prolonged intubation, resulting in extended opioid exposure that is associated with poor outcomes. Understanding variation in opioid prescribing can inform quality improvement and best-practice initiatives.

Objective

To examine regional and institutional variation in opioid prescribing, including short- and long-acting agents, in high-risk hospitalized infants.

Design, Setting, and Participants

This retrospective cohort study assessed high-risk infants younger than 1 year from January 1, 2016, to December 31, 2022, at 47 children's hospitals participating in the Pediatric Health Information System (PHIS). The cohort was stratified by US Census region (Northeast, South, Midwest, and West). Variation in cumulative days of opioid exposure and methadone treatment was examined among institutions using a hierarchical generalized linear model. High-risk infants were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and other abdominal surgery. Infants with neonatal opioid withdrawal syndrome, in utero substance exposure, or malignant tumors were excluded.

Exposure

Any opioid exposure and methadone treatment.

Main Outcomes and Measures

Regional and institutional variations in opioid exposure.

Results

Overall, 132 658 high-risk infants were identified (median [IQR] gestational age, 34 [28-38] weeks; 54.5% male). Prematurity occurred in 30.3%, and 55.3% underwent surgery. During hospitalization, 76.5% of high-risk infants were exposed to opioids and 7.9% received methadone. Median (IQR) length of any opioid exposure was 5 (2-12) cumulative days, and median (IQR) length of methadone treatment was 19 (7-46) cumulative days. There was significant hospital-level variation in opioid and methadone exposure and cumulative days of exposure within each US region. The computed intraclass correlation coefficient estimated that 16% of the variability in overall opioid prescribing and 20% of the variability in methadone treatment was attributed to the individual hospital.

Conclusions and Relevance

In this retrospective cohort study of high-risk hospitalized infants, institution-level variation in overall opioid exposure and methadone treatment persisted across the US. These findings highlight the need for standardization of opioid prescribing in this vulnerable population.

Factors Associated With Safe Prescription Opioid Disposal After Surgery in Adolescents

INTRODUCTION

Unused prescription opioids contribute to diversion, unintended exposure, and poisonings in adolescents. Factors associated with safe prescription opioid disposal for adolescents undergoing surgery are unknown.

METHODS

Parents of adolescents (13-20 y) undergoing surgery associated with an opioid prescription were enrolled preoperatively. Parents completed a baseline survey measuring sociodemographics and family history of substance abuse and two postoperative surveys capturing opioid use and disposal at 30 and 90 d. Safe disposal was defined as returning opioids to a healthcare facility, pharmacy, take-back event, or a police station. Factors associated with safe opioid disposal were assessed using bivariate analysis.

RESULTS

Of 119 parent-adolescent dyads, 90 (76%) reported unused opioids after surgery. The majority of parents reporting unused opioids completed the surveys in English (80%), although many (44%) spoke another language at home. Most reported income levels <$60,000 (54%), did not attend college (69%), and had adequate health literacy (66%). Most parents (78%) did not report safe opioid disposal. Safe opioid disposal was associated with younger patient age, (median 14 y, IQR 13-16.5 versus median 15.5 y, IQR 14-17, P = 0.031), fewer days taking opioids (median 5, IQR 2-6 versus median 7, IQR 4-14, P = 0.048), and more leftover pills (median 20, IQR 10-35 versus median 10, IQR 5-22, P = 0.008).

CONCLUSIONS

Most parents fail to safely dispose of unused opioids after their adolescent's surgery. Younger patient age, shorter duration of opioid use, and higher number of unused pills were associated with safe disposal. Interventions to optimize prescribing and educate parents about safe opioid disposal are warranted.

Postoperative Opioid Prescribing, Use, and Disposal in Children

This article provides an overview of postoperative opioid prescribing, use, and disposal patterns in children and also identifies gaps in knowledge and areas for improvement. We present evidence that there is a need to tailor prescriptions to specific procedures to reduce the number of excess, unused prescription opioid pills in the home. We also explain the need to provide culturally competent care when managing a child's pain after surgery. Finally, we discuss the need for widespread provider and caregiver education about safe prescription opioid use, storage, and disposal.

Overprescribing and Undereducating: a Survey of Pre- and Postoperative Pain Protocols for Pediatric Anterior Cruciate Ligament Surgery

Purpose

To establish a better understanding of the variations in pain management protocols and prescribing patterns for pediatric patients undergoing anterior cruciate ligament (ACL) reconstruction or repair.

Methods

A 20-question multiple-choice survey was distributed to 3 professional orthopaedic societies to assess the pre-emptive and postoperative pain management prescribing patterns for pediatric patients undergoing ACL reconstruction or repair. Clinical agreement (defined as agreement between >80% of participants) and general agreement (defined as agreement between >60% of participants) were calculated based on responses as previously reported.

Results

Clinical agreement was observed among the 68 respondents in use of a single shot nerve block before induction of anesthesia versus continuous use when a peripheral nerve block was used, “always” counseling patients on postoperative pain control, the prescribing of opioids postoperatively, and a lack of change in postoperative protocol when concomitant meniscal repair or meniscectomy was performed. General agreement was observed in the use of a peripheral nerve block, some pre-emptive analgesia practices, and the lack of counseling patients with regard to disposal of unused opioid pain medication postoperatively. Opioids were prescribed by 88% of participants postoperatively, with 48% prescribing 11 to 19 pills and 15% prescribing ≥20 pills.

Conclusions

While pain management practices before and following ACL reconstruction and repair in the pediatric population remain varied, opioids are frequently prescribed postoperatively with many providers neglecting to provide instruction on excess opioid disposal.

Clinical Relevance

ACL reconstruction and repair is becoming increasingly common in the pediatric population. Clinical guidelines that establish pre-emptive and postoperative pain-control protocols should be considered to determine safe and optimal pain control throughout the duration of care while minimizing opioid prescribing and consumption.

Post-Procedural Opioid Prescribing in Children: A Survey of the American Academy of Pediatrics

INTRODUCTION

North America is in the midst of an opioid epidemic. The role of pediatric surgeons and other procedural specialists in this public health crisis remains unclear. There is likely considerable variation in the use of opioid and non-opioid analgesics, but the spectrum of practice is still uncertain.

METHODS

We performed an online survey in July 2018 of the 2086 pediatric surgeons and proceduralists who were active members in the American Academy of Pediatrics. The survey inquired about practice environment, use of opioid and non-opioid pain medications, and attitudes towards the opioid epidemic.

RESULTS

178 specialists completed the survey for a response rate of 8.5%. Most respondents utilize oral acetaminophen (86%) and ibuprofen (80%) after procedures >75% of the time. Self-reported opioid prescribing increases with age after both outpatient and inpatient procedures (P < 0.001). Pediatric general surgeons prescribe opioids less frequently than other specialists, particularly after inpatient procedures. The majority of respondents (81%) believe that the opioid epidemic is a major problem but only 31% indicated that they have a major role to play.

CONCLUSIONS

There is significant variation in opioid prescribing patterns as reported by pediatric surgeons and proceduralists. Guidelines are needed to standardize the use of non-opioid analgesics and decrease reliance on opioids for outpatient and inpatient procedures.