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Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW, Dhar V, Dionne RA, Espinoza L, Gordon SM, Hersh EV, Law AS, Li BSK, Schwartz PJ, Suda KJ, Turturro MA, Wright ML, Dawson T, Miroshnychenko A, Pahlke S, Pilcher L, Shirey M, Tampi M, Moore PA. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania. J Am Dent Assoc 2023; 154:814-825.e2. [PMID: 37634915 PMCID: PMC10910586 DOI: 10.1016/j.adaj.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/26/2023] [Accepted: 06/01/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND A guideline panel convened by the American Dental Association Council on Scientific Affairs, American Dental Association Science and Research Institute, University of Pittsburgh School of Dental Medicine, and Center for Integrative Global Oral Health at the University of Pennsylvania conducted a systematic review and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after 1 or more simple and surgical tooth extractions and the temporary management of toothache (that is, when definitive dental treatment not immediately available) associated with pulp and furcation or periapical diseases in children (< 12 years). TYPES OF STUDIES REVIEWED The authors conducted a systematic review to determine the effect of analgesics and corticosteroids in managing acute dental pain. They used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. RESULTS The panel formulated 7 recommendations and 5 good practice statements across conditions. There is a small beneficial net balance favoring the use of nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen compared with not providing analgesic therapy. There is no available evidence regarding the effect of corticosteroids on acute pain after surgical tooth extractions in children. CONCLUSIONS AND PRACTICAL IMPLICATIONS Nonopioid medications, specifically nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen alone or in combination with acetaminophen, are recommended for managing acute dental pain after 1 or more tooth extractions (that is, simple and surgical) and the temporary management of toothache in children (conditional recommendation, very low certainty). According to the US Food and Drug Administration, the use of codeine and tramadol in children for managing acute pain is contraindicated.
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Voepel-Lewis T, Malviya S, Grant JA, Dwyer S, Becher A, Schwartz JH, Tait AR. Effect of a brief scenario-tailored educational program on parents' risk knowledge, perceptions, and decisions to administer prescribed opioids: a randomized controlled trial. Pain 2021; 162:976-985. [PMID: 33009245 PMCID: PMC7886960 DOI: 10.1097/j.pain.0000000000002095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT This randomized, controlled trial evaluated whether a brief educational program (ie, Scenario-Tailored Opioid Messaging Program [STOMP]) would improve parental opioid risk knowledge, perceptions, and analgesic efficacy; ensure safe opioid use decisions; and impact prescription opioid use after surgery. Parent-child dyads (n = 604) who were prescribed an opioid for short-term use were randomized to routine instruction (Control) or routine plus STOMP administered preoperatively. Baseline and follow-up surveys assessed parents' awareness and perceived seriousness of adverse opioid effects, and their analgesic efficacy. Parents' decisions to give an opioid in hypothetical scenarios and total opioid doses they gave to children at home were assessed at follow-up. Scenario-Tailored Opioid Messaging Program parents gained enhanced perceptions of opioid-related risks over time, whereas Controls did not; however, risk perceptions did not differ between groups except for addiction risk. Scenario-Tailored Opioid Messaging Program parents exhibited marginally greater self-efficacy compared to Controls (mean difference vs controls = 0.58 [95% confidence interval 0.08-1.09], P = 0.023). Scenario-Tailored Opioid Messaging Program parents had a 53% lower odds of giving an opioid in an excessive sedation scenario (odds ratio 0.47 [95% confidence interval 0.28-0.78], P = 0.003), but otherwise made similar scenario-based opioid decisions. Scenario-Tailored Opioid Messaging Program was not associated with total opioid doses administered at home. Instead, parents' analgesic efficacy and pain-relief preferences explained 7%, whereas child and surgical factors explained 22% of the variance in opioid doses. Scenario-tailored education enhanced parents' opioid risk knowledge, perceptions, and scenario-based decision-making. Although this may inform later situation-specific decision-making, our research did not demonstrate an impact on total opioid dosing, which was primarily driven by surgical and child-related factors.
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Affiliation(s)
- Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109
- School of Nursing, University of Michigan, Ann Arbor, MI 48109
| | - Shobha Malviya
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109
| | - John A. Grant
- Department of Orthopedic Surgery at the University of Michigan, Ann Arbor, MI 48109
| | - Sarah Dwyer
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109
| | - Asif Becher
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109
| | - Jacob H. Schwartz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109
| | - Alan R. Tait
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109
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Kelley-Quon LI, Kirkpatrick MG, Ricca RL, Baird R, Harbaugh CM, Brady A, Garrett P, Wills H, Argo J, Diefenbach KA, Henry MCW, Sola JE, Mahdi EM, Goldin AB, St Peter SD, Downard CD, Azarow KS, Shields T, Kim E. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg 2021; 156:76-90. [PMID: 33175130 PMCID: PMC8995055 DOI: 10.1001/jamasurg.2020.5045] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
IMPORTANCE Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking. OBJECTIVE To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery. EVIDENCE REVIEW Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique. FINDINGS Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery. CONCLUSIONS AND RELEVANCE These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.
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Affiliation(s)
- Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Preventive Medicine, University of Southern California, Los Angeles
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | | | - Robert L Ricca
- Department of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Robert Baird
- Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ashley Brady
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Paula Garrett
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Hale Wills
- Division of Pediatric Surgery, Hasbro Children's Hospital, Providence, Rhode Island
- Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jonathan Argo
- Department of Pediatric Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Marion C W Henry
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Kenneth S Azarow
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland
| | - Tracy Shields
- Division of Library Services, Naval Medical Center, Portsmouth, Virginia
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Voepel-Lewis T, Farley FA, Grant J, Tait AR, Boyd CJ, McCabe SE, Weber M, Harbagh CM, Zikmund-Fisher BJ. Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial. Pediatrics 2020; 145:e20191431. [PMID: 31871245 PMCID: PMC6939843 DOI: 10.1542/peds.2019-1431] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Leftover prescription opioids pose risks to children and adolescents, yet many parents keep these medications in the home. Our objective in this study was to determine if providing a behavioral disposal method (ie, Nudge) with or without a Scenario-Tailored Opioid Messaging Program (STOMP) (risk-enhancement education) improves parents' opioid-disposal behavior after their children's use. METHODS Parents whose children were prescribed a short course of opioids were recruited and randomly assigned to the Nudge or control groups with or without STOMP. Parents completed surveys at baseline and 7 and 14 days. Main outcomes were (1) prompt disposal (ie, immediate disposal of leftovers after use) and (2) planned retention (intention to keep leftovers). RESULTS There were 517 parents who took part, and 93% had leftovers after use. Prompt disposal behavior was higher for parents who received both the STOMP and Nudge interventions (38.5%), Nudge alone (33.3%), or STOMP alone (31%) compared with controls (19.2%; P ≤ .02). Furthermore, the STOMP intervention independently decreased planned retention rates (5.6% vs 12.5% no STOMP; adjusted odds ratio [aOR] 0.40 [95% confidence interval (CI) 0.19-0.85]). Higher risk perception lowered the odds of planned retention (aOR 0.87 [95% CI 0.79-0.96]), whereas parental past opioid misuse increased those odds (aOR 4.44 [95% CI 1.67-11.79]). CONCLUSIONS Providing a disposal method nudged parents to dispose of their children's leftover opioids promptly after use, whereas STOMP boosted prompt disposal and reduced planned retention. Such strategies can reduce the presence of risky leftover medications in the home and decrease the risks posed to children and adolescents.
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Affiliation(s)
- Terri Voepel-Lewis
- Departments of Anesthesiology,
- Health Behaviors and Biological Science, School of Nursing, and
| | | | | | | | - Carol J Boyd
- Health Behaviors and Biological Science, School of Nursing, and
- Psychiatry
| | | | | | | | - Brian J Zikmund-Fisher
- Division of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan
- Internal Medicine, and
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Razdan R, Stevens L, Ritchie M, Kennedy T, Carr MM. Parents' attitudes toward post-operative narcotic use in pediatric patients. Int J Pediatr Otorhinolaryngol 2019; 124:173-178. [PMID: 31202034 DOI: 10.1016/j.ijporl.2019.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/01/2019] [Accepted: 06/01/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To understand parent perceptions of post-operative narcotic use in the pediatric otolaryngology patient population. METHODS This was a descriptive survey of caregivers on children being seen in a university pediatric otolaryngology clinic. Caregiver role, age of child, previous exposure to analgesics, choice of analgesics, comfort and concern with narcotic use in this child, knowledge of narcotic side effects, and knowledge about narcotic disposal were included. Comfort and concern questions were scored on a 10-point VAS where the higher numbers indicated more concern/discomfort. RESULTS 301 caregivers participated, 84.5% were mothers, 11% were fathers and the rest were custodial grandparents. 45.2% knew someone addicted to narcotics. Respondents were uncomfortable with their child experiencing pain in a hypothetical postoperative situation, with 63.9% having at least some discomfort with it. First choice of medication to treat hypothetical post-tonsillectomy pain was ibuprofen (47.5%) followed by acetaminophen (38.9%). 29.9% were concerned about addiction, and 26.6% were concerned about drowsiness as a sequela of narcotic use. There were significant differences between respondents who knew a person addicted to narcotics and those who did not for comfort using narcotics in their child (VAS median 6.0 versus 5.0, p = 0.025), concern that their child would become addicted to narcotics (VAS median 5.0 versus 2.0, p = 0.001), concern about side effects (VAS median 7.0 versus 6.0, p = 0.007) and concern about having narcotics in the home (VAS median 3.0 versus 0.0, p < 0.001). CONCLUSIONS The national opioid epidemic exposes more parents to narcotic addiction in the community, which affects their perceptions of pediatric post-operative narcotic use. These experiences may need to be considered when planning postoperative pain management strategies in children.
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Affiliation(s)
- Reena Razdan
- West Virginia College of Medicine, Morgantown, WV, USA
| | - Levi Stevens
- Department of Otolaryngology, West Virginia University, Morgantown, WV, USA
| | - Michelle Ritchie
- Department of Otolaryngology, West Virginia University, Morgantown, WV, USA
| | - Travis Kennedy
- Department of Pediatrics, West Virginia University, Morgantown, WV, USA
| | - Michele M Carr
- Department of Otolaryngology, West Virginia University, Morgantown, WV, USA.
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Voepel-Lewis T, Tait AR, Becher A, Levine R. An interactive web-based educational program improves prescription opioid risk knowledge and perceptions among parents. Pain Manag 2019; 9:369-377. [PMID: 31215347 DOI: 10.2217/pmt-2019-0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim: This study evaluated the effect of an interactive, web-based educational program on parents' opioid risk knowledge, risk perceptions, analgesic self efficacy and decision-making. Patients & methods: Totally, 64 parents from a tertiary care pediatric healthcare setting were assessed for risk understanding at baseline, immediately and 3 days after receiving the educational program. Results: Participants gained increased opioid risk knowledge, enhanced risk perceptions as well as enhanced analgesic self efficacy after program exposure. The program had no effect on parental decisions about when to give or withhold a prescribed opioid. Conclusion: The interactive web-based program improved parental knowledge about opioid risks. Program enhancements may be needed to improve pain management decisions about when it is safe to use opioids and when they should be withheld.
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Affiliation(s)
- Terri Voepel-Lewis
- University of Michigan School of Nursing Center for the Study of Drugs, Alcohol Smoking & Health, Miami, FL 48109, USA.,Department of Anesthesiology, Miami, FL, USA
| | - Alan R Tait
- Department of Anesthesiology, Miami, FL, USA
| | - Asif Becher
- Department of Anesthesiology, Miami, FL, USA
| | - Robert Levine
- Emergency Care Center, Jackson Memorial Hospital, Miami, FL, USA.,ArchieMD, Inc., Boca Raton, FL, USA
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Du X, Gu J. The efficacy and safety of parecoxib for reducing pain and opioid consumption following total knee arthroplasty: A meta-analysis of randomized controlled trials. Int J Surg 2018; 59:67-74. [DOI: 10.1016/j.ijsu.2018.09.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 11/28/2022]
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Voepel-Lewis T, Boyd CJ, McCabe SE, Zikmund-Fisher BJ, Malviya S, Grant J, Weber M, Tait AR. Deliberative Prescription Opioid Misuse Among Adolescents andEmerging Adults: Opportunities for Targeted Interventions. J Adolesc Health 2018; 63:594-600. [PMID: 30348282 PMCID: PMC6658888 DOI: 10.1016/j.jadohealth.2018.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/20/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND One in five adolescents and emerging adults have reported prescription opioid misuse (POM), posing significant risks for opioid-related adverse outcomes. Devising prevention strategies requires a better understanding of the decisional factors underlying risky misuse behavior. This research examined the associations between past opioid use behavior, opioid risk knowledge and perceptions, and intentional POM decisions. METHODS Participants aged 15-23years completed surveys assessing past prescription opioid use and misuse, opioid risk knowledge, opioid risk perceptions, and pain relief preferences (i.e., analgesic benefit vs. risk aversion preference). The outcome, Willingness to Misuse (i.e., intentional decisions to use a prescription opioid in a non-compliant manner) was measured using hypothetical pain decision scenarios. RESULTS Surveys were completed by 972 adolescents and young adults. In total, 44% had taken a prescription opioid and 32% of these reported past POM. Willingness to Misuse was significantly associated with lower opioid misuse risk perceptions (β = .75 [95% CI .66-.86]) and past opioid misuse (β = 1.81 [95% CI 1.13-2.91]) but not simple risk knowledge (β = .81 [95% CI .58-1.11]. The probability of future misuse was highest for those who reported past opioid misuse and had low risk perceptions (58.7% [95% CI 51.3-65.8]) and high pain relief preferences (53.4% [95% CI 45.3%-61.3%]). CONCLUSIONS Findings suggest that simple knowledge of prescription opioid risks is insufficient to curtail misuse among adolescents and emerging adults. Rather, it may be important to heighten opioid risk perceptions and strengthen opioid risk aversion values when prescribing opioid analgesics to better prevent future misuse in this high risk population.
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Affiliation(s)
- Terri Voepel-Lewis
- Department of Anesthesiology, Children's and Women's Hospital, University of Michigan, Ann Arbor, Michigan.
| | - Carol J Boyd
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Sean E McCabe
- Institute for Research on Women and Gender, University of Michigan, Ann Arbor, Michigan
| | - Brian J Zikmund-Fisher
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Shobha Malviya
- Department of Anesthesiology, Children's and Women's Hospital, University of Michigan, Ann Arbor, Michigan
| | - John Grant
- Departments of Orthopaedic Surgery and Sports Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Monica Weber
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Alan R Tait
- Department of Anesthesiology, Children's and Women's Hospital, University of Michigan, Ann Arbor, Michigan
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Dash GF, Wilson AC, Morasco BJ, Feldstein Ewing SW. A Model of the Intersection of Pain and Opioid Misuse in Children and Adolescents. Clin Psychol Sci 2018; 6:629-646. [PMID: 30333942 PMCID: PMC6186448 DOI: 10.1177/2167702618773323] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Despite being a significant public health concern, the role of opioid prescriptions in potentiating risk of opioid misuse in the context of pediatric pain has been under-investigated. To address this gap, the present review identifies theory-based hypotheses about these associations, reviews the extant literature on opioid prescriptions that supports these hypotheses, and provides routes for future empirical studies. A multi-level model of mechanisms through which opioid prescriptions may impact pain and other negative outcomes in youth, including risk for opioid misuse and related problems, is proposed with particular attention paid to the role that psychologists can play in informing policies and developing preventative interventions in healthcare settings.
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Affiliation(s)
- Genevieve F. Dash
- Department of Psychological Sciences, University of Missouri, Columbia, MO USA
| | - Anna C. Wilson
- Department of Pediatrics, Institute on Development and Disability, Oregon Health & Science University, Portland, OR USA
| | - Benjamin J. Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System; Department of Psychiatry, Oregon Health & Science University, Portland, OR USA
| | - Sarah W. Feldstein Ewing
- Department of Child & Adolescent Psychiatry, Oregon Health & Science University, Portland, OR USA
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Voepel-Lewis T, Zikmund-Fisher BJ, Boyd CJ, Veliz PT, McCabe SE, Weber M, Tait AR. Effect of a Scenario-tailored Opioid Messaging Program on Parents' Risk Perceptions and Opioid Decision-making. Clin J Pain 2018; 34:497-504. [PMID: 29135696 PMCID: PMC5934298 DOI: 10.1097/ajp.0000000000000570] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Poor parental understanding of prescription opioid risks is associated with potentially dangerous decisions that can contribute to adverse drug events (ADE) in children and adolescents. This study examined whether an interactive Scenario-tailored Opioid Messaging Program (STOMP) would (1) enhance opioid risk perceptions and (2) improve the safety of parents' decision-making. MATERIALS AND METHODS In total, 546 parents were randomized to receive the STOMP versus control information and 516 completed the program. A baseline survey assessed parents' opioid risk knowledge, perceptions, and preferences for pain relief versus risk avoidance (Pain Relief Preference). Parents then made hypothetical decisions to give or withhold a prescribed opioid for high-risk (excessive sedation) and low-risk (no ADE) scenarios. The STOMP provided immediate feedback with specific risk and guidance information; the control condition provided general information. We reassessed knowledge, perceptions, and decision-making up to 3 days thereafter. RESULTS Following the intervention, the STOMP group became more risk avoidant (Pain Relief Preference, mean difference -1.27 [95% confidence interval, -0.8 to -1.75]; P<0.001) and gained higher perceptions of the critical risk, excessive sedation (+0.56 [0.27 to 0.85]; P<0.001). STOMP parents were less likely than controls to give a prescribed opioid in the high-risk situation (odds ratio, -0.14 [-0.24 to -0.05]; P=0.006) but similarly likely to give an opioid for the no ADE situation (P=0.192). DISCUSSION The STOMP intervention enhanced risk perceptions, shifted preferences toward opioid risk avoidance, and led to better decisions regarding when to give or withhold an opioid for pain management. Scenario-tailored feedback may be an effective method to improve pain management while minimizing opioid risks.
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Affiliation(s)
- Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan, Ann Arbor MI 48109-4245
| | - Brian J. Zikmund-Fisher
- Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor MI 48109-4245
| | - Carol J. Boyd
- Institute for Research on Women and Gender, University of Michigan, Ann Arbor MI 48109-4245
| | - Philip T. Veliz
- Institute for Research on Women and Gender, University of Michigan, Ann Arbor MI 48109-4245
| | - Sean Esteban McCabe
- Institute for Research on Women and Gender, University of Michigan, Ann Arbor MI 48109-4245
| | - Monica Weber
- Department of Anesthesiology, University of Michigan, Ann Arbor MI 48109-4245
| | - Alan R. Tait
- Anesthesiology, University of Michigan, Ann Arbor MI 48109-4245
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Zhao T, Shen Z, Sheng S. The efficacy and safety of nefopam for pain relief during laparoscopic cholecystectomy: A meta-analysis. Medicine (Baltimore) 2018; 97:e0089. [PMID: 29517677 PMCID: PMC5882431 DOI: 10.1097/md.0000000000010089] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Pain control after laparoscopic cholecystectomy (LC) has become an important topic. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of nefopam for pain management after LC. METHODS PubMed, Medline, Embase, ScienceDirect, and the Cochrane Library were searched up to November 2017 for comparative articles involving nefopam and placebo for reducing postoperative pain after LC. Primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes were length of hospital stay, opioid-related adverse effects, and postoperative complications. We assessed statistical heterogeneity for each RCT by using a standard Chi test and the I statistic. The meta-analysis was undertaken using Stata 12.0. RESULTS A total of 215 patients were analyzed across 4 RCTs. We found that there were significant differences between nefopam and placebo groups regarding the postoperative pain scores and opioid requirements at 6, 12, and 24 hours. Moreover, there was a decreased risk of opioid-related adverse effects in the nefopam groups. No significant differences were identified in terms of the incidence of postoperative complications. CONCLUSION Intravenous nefopam infusion resulted in significant reduction in postoperative pain scores and opioid requirements while decreasing opioid-related adverse effects. Additionally, no increased risk of venous thromboembolism was found. The current evidence suggests that more RCTs will be needed in further investigations.
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Affiliation(s)
| | - Zhen Shen
- Department of Gastrointestinal Surgery, China–Japan Union Hospital of Jilin University, Jilin, China
| | - Shihou Sheng
- Department of Gastrointestinal Surgery, China–Japan Union Hospital of Jilin University, Jilin, China
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12
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Tait AR, Bickham R, O'Brien LM, Quinlan M, Voepel-Lewis T. The STBUR questionnaire for identifying children at risk for sleep-disordered breathing and postoperative opioid-related adverse events. Paediatr Anaesth 2016; 26:759-66. [PMID: 27219118 DOI: 10.1111/pan.12934] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Children with symptoms of sleep-disordered breathing (SDB) appear to be at risk for perioperative respiratory events (PRAE). Furthermore, these children may be more sensitive to the respiratory-depressant effects of opioids compared with children without SDB. AIMS The aim of this prospective observational study was to confirm that otherwise healthy children with symptoms of SDB are at greater risk for PRAE compared with children with no symptoms and to determine if these children are also at increased risk for postoperative opioid-related adverse events (ORAE). METHODS Six hundred and seventy-eight parents of children scheduled for surgery completed the Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire preoperatively. Data regarding the incidence of PRAE were collected prospectively. Postoperative pulse oximetry desaturation alarm events were downloaded from the institutional secondary alarm notification system. RESULTS Children with symptoms of SDB per STBUR (≥3 symptoms) had a two-fold increased likelihood of PRAE compared with children without SDB (52.8% vs 27.9% respectively, LR(+) = 2.00, 95% CI = 1.60-2.49, P = 0.0001). A subset analysis of children undergoing airway procedures requiring hospital admittance (n = 179) showed that those with SDB were given the same postoperative opioid doses as children without SDB. However, children with SDB symptoms generated a greater number of postoperative oxygen desaturation alarms (14.14 ± 29.3 vs 7.12 ± 13.2, mean difference = 7.02, 95% CI = 0.39-13.64, P = 0.038) and more frequently required escalation of care (15.3% vs 7.1%, LR(+) = 1.67, 95% CI = 1.22-2.16, P = 0.001) compared with children with no SDB symptoms. CONCLUSIONS Children presenting for surgery with SDB symptoms are at increased risk for PRAE. Children undergoing airway-related procedures also appear to be at increased risk for ORAE. Furthermore, regardless of the preoperative assessment of risk using the STBUR questionnaire, children received the same doses of opioids postoperatively. Given the increased incidence of postoperative oxygen desaturations among children with SDB symptoms, it would seem prudent to consider titration of opioid doses according to identified risk.
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Affiliation(s)
- Alan R Tait
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Rebecca Bickham
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA.,The University of Michigan Medical School, University of Michigan Health System, Ann Arbor, MI, USA
| | - Louise M O'Brien
- Department of Neurology, University of Michigan Health System, Ann Arbor, MI, USA.,Department of Oral/Maxillofacial Surgery, University of Michigan Health System, Ann Arbor, MI, USA.,The Michael S. Aldridge Sleep Disorders Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Megan Quinlan
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA.,The University of Michigan Medical School, University of Michigan Health System, Ann Arbor, MI, USA
| | - Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
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Schymik FA, Lavoie Smith EM, Voepel-Lewis T. Parental Analgesic Knowledge and Decision Making for Children With and Without Obstructive Sleep Apnea After Tonsillectomy and Adenoidectomy. Pain Manag Nurs 2015; 16:881-9. [DOI: 10.1016/j.pmn.2015.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023]
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Tait AR, Voepel-Lewis T. Sleep-Disordered Breathing--Not Just for Grownups Anymore. J Perianesth Nurs 2015; 30:566-570. [PMID: 26596395 DOI: 10.1016/j.jopan.2015.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 09/12/2015] [Indexed: 10/22/2022]
Abstract
Previous research on SDB in children has focus edprimarily on OSA, whereas there is an increasing body of evidence to suggest that children with a spectrum of SDB symptoms may be at risk for perioperative and postoperative adverse events. To this end, it is imperative that these children are identified before surgery so that anesthesia and postoperative pain management plans can be optimized to mitigate risk. Although PSG remains the gold standard as a means to screen for SDB preoperatively,there are now clinically valid tools that can be used as part of the preanesthetic interview to identify children at risk. However, although recent work suggests that implementation of such screening tools may be important in identifying at-risk children and reducing perioperative adverse events through changes in anesthetic management, there is still much to be done with respect to changing the culture of standard postoperative opioid dosing. Perianesthesia nurses are thus in a unique position to help encourage a culture in which SDB in children is recognized asa significant risk for both perioperative and potentially deadly postoperative sequelae.
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Voepel-Lewis T, Zikmund-Fisher BJ, Smith EL, Zyzanski S, Tait AR. Parents’ preferences strongly influence their decisions to withhold prescribed opioids when faced with analgesic trade-off dilemmas for children: A prospective observational study. Int J Nurs Stud 2015; 52:1343-53. [DOI: 10.1016/j.ijnurstu.2015.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/30/2015] [Accepted: 05/03/2015] [Indexed: 11/27/2022]
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Voepel-Lewis T. What They Don't Know Can Hurt Them: Risky Analgesic Use in Children. J Perianesth Nurs 2015. [PMID: 26210571 DOI: 10.1016/j.jopan.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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