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Hall EA, Shelton CM, Hagemann TM, Jasmin HM, Grey K, Anghelescu DL. A Narrative Review of Pain in Pediatric Oncology: The Opioid Option for Procedural and Surgical Pain. Paediatr Drugs 2024:10.1007/s40272-024-00654-6. [PMID: 39333447 DOI: 10.1007/s40272-024-00654-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2024] [Indexed: 09/29/2024]
Abstract
This narrative review examines the evolving role of opioids in managing procedural and surgical pain in pediatric oncology patients. The review evaluates studies on opioid use across various oncological surgeries including thoracic, abdominal, orthopedic, and neurosurgical procedures, as well as for common painful procedures such as bone marrow aspirations and lumbar punctures. While opioids remain important for acute procedural and postoperative pain management in pediatric oncology patients, there is an increasing emphasis on multimodal, opioid-sparing approaches. The evidence presented within this review highlights the growing focus on judicious postoperative opioid prescribing to mitigate risks of adverse effects and persistent use or potential misuse. The review synthesizes findings from studies investigating various analgesic regimens, including the use of regional anesthesia techniques like epidural analgesia and peripheral nerve blocks, which have shown promise in reducing opioid requirements. For procedural pain, the review explores the efficacy of combining opioids with sedatives like midazolam or propofol, as well as the potential of ketamine as an opioid-sparing alternative. Key findings indicate that opioid-sparing techniques can effectively reduce overall opioid consumption without compromising pain control or patient satisfaction. Several studies demonstrated that regional anesthesia techniques and non-opioid adjuncts can significantly lower postoperative opioid requirements across various surgical procedures. For procedural pain, ketamine-based regimens often showed comparable or superior pain control to opioid-based approaches, with some studies reporting better patient satisfaction. This review also addresses the importance of tailored postoperative opioid prescribing, with some studies presenting algorithms to predict outpatient opioid needs more accurately. These approaches aim to ensure adequate pain control while minimizing excess opioid dispensing.
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Affiliation(s)
- Elizabeth A Hall
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Chasity M Shelton
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy M Hagemann
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hilary M Jasmin
- Health Sciences Library, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karissa Grey
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Doralina L Anghelescu
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
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Odegard M, Ourshalimian S, Hijaz D, Goldstein RY, Ignacio RC, Chen SY, Kim E, Kim ES, Kelley-Quon LI. Factors Associated with Postoperative Opioid Use in Adolescents. J Pediatr Surg 2024; 59:709-717. [PMID: 38097461 DOI: 10.1016/j.jpedsurg.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/15/2023] [Accepted: 11/20/2023] [Indexed: 04/08/2024]
Abstract
BACKGROUND We aimed to identify factors associated with postoperative prescription opioid use in adolescents. METHODS Adolescents aged 13-20 years undergoing surgery were prospectively recruited from a children's hospital. Adolescent-parent dyads completed a preoperative survey, measuring clinical and sociodemographic factors, and two postoperative surveys evaluating self-reported opioid use at 30- and 90-days. Poisson regression analysis identified factors associated with the number of pills used within 90-days, adjusting for age, gender, race/ethnicity, surgery type, and pain at discharge. RESULTS We enrolled 119 adolescents who reported postoperative opioid use following posterior spinal fusion (PSF) (50 %), arthroscopy (23 %), pectus excavatum repair (11 %), tonsillectomy (8 %), and hip reconstruction (7 %). Overall, 81 % of adolescents reported unused opioids. The median pain score at discharge was 7 (IQR:5-8). Adolescents reported using a median of 7 (IQR:2-15) opioid pills, with 20 (IQR:7-30) pills left unused. Compared to all other surgeries, adolescents undergoing PSF reported the highest median pill use (10, IQR:5-29; p = 0.004). Adolescents undergoing tonsillectomy reported the lowest median pill use (1, IQR:0-7; p = 0.03). On regression analysis, older patient age was associated with a 12 % increase in pill use (95 % CI:3%-23 %). Undergoing PSF was associated with a 63 % increase in pill use (95 % CI:15%-31 %). Each additional pain scale point reported at discharge was associated with a 13 % increase in pill use (95 % CI:5%-22 %). CONCLUSIONS Older age, surgery type, and patient-reported pain at discharge are associated with postoperative prescription opioid use in adolescents. Understanding patient and surgery-specific factors associated with opioid use may guide surgeons to minimize excess opioid prescribing. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Rachel Y Goldstein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Romeo C Ignacio
- Rady Children's Hospital San Diego, 3020 Children's Way, San Diego, CA, 92123, USA
| | - Stephanie Y Chen
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Eugene Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA; Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA; Department of Population and Public Health Sciences, University of Southern California, 1845 N. Soto Dr., Los Angeles, CA, 90032, USA
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Odegard MN, Ourshalimian S, Hijaz D, Chen SY, Kim E, Illingworth K, Kelley-Quon LI. Factors Associated With Safe Prescription Opioid Disposal After Surgery in Adolescents. J Surg Res 2022; 279:42-51. [PMID: 35717795 PMCID: PMC10771859 DOI: 10.1016/j.jss.2022.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 05/21/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Marjorie N Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Kenneth Illingworth
- Division of Orthopedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California.
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Odegard M, Kelley-Quon LI. Postoperative Opioid Prescribing, Use, and Disposal in Children. Adv Pediatr 2022; 69:259-271. [PMID: 35985715 DOI: 10.1016/j.yapd.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA.
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA 90033, USA
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Devine KJ, Diorio C, Richman SA, Henderson AA, Oranges K, Armideo E, Kolb MS, Freedman JL, Aplenc R, Fisher MJ, Minturn JE, Olson T, Bagatell R, Barakat L, Croy C, Mauro J, Vitlip L, Acord MR, Mattei P, Johnson VK, Devine CM, Pasquariello C, Reilly AF. Guideline for Children With Cancer Receiving General Anesthesia for Procedures and Imaging. J Pediatr Hematol Oncol 2022; 44:e859-e865. [PMID: 35235547 DOI: 10.1097/mph.0000000000002430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
Abstract
Children with cancer and those undergoing hematopoietic stem cell transplantation frequently require anesthesia for imaging as well as diagnostic and therapeutic procedures from diagnosis through follow-up. Due to their underlying disease and side effects of chemotherapy and radiation, they are at risk for complications during this time, yet no published guideline exists for preanesthesia preparation. A comprehensive literature review served as the basis for discussions among our multidisciplinary panel of oncologists, anesthesiologists, nurse practitioners, clinical pharmacists, pediatric psychologists, surgeons and child life specialists at the Children's Hospital of Philadelphia. Due to limited literature available, this panel created an expert consensus guideline addressing anesthesia preparation for this population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Lamia Barakat
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Colleen Croy
- Division of Oncology
- Department of Pharmacy, Children's Hospital of Philadelphia
| | - Jane Mauro
- Division of Oncology
- Department of Pharmacy, Children's Hospital of Philadelphia
| | | | - Michael R Acord
- Division of Interventional Radiology
- Radiology, Perelman School of Medicine at the University of Pennsylvania
| | - Peter Mattei
- Surgery, The Children's Hospital of Philadelphia
| | - Victoria K Johnson
- Justin Ingerman Center for Palliative Care, The Children's Hospital of Philadelphia
| | - Conor M Devine
- Division of Otolaryngology
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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