Effect of a Scenario-tailored Opioid Messaging Program on Parents' Risk Perceptions and Opioid Decision-making

Adolescent and Parent Perceptions of Postoperative Opioid Use: A Qualitative, Thematic Analysis

BACKGROUND

Little is known about how families make decisions regarding postoperative prescription opioid consumption. This qualitative study examines adolescent and parent perspectives on postoperative prescription opioid use.

METHODS

We recruited adolescents aged 13-20 years old who received a postoperative opioid prescription and their parents from a previous longitudinal cohort study. We employed purposive sampling for recruitment to reflect local community sociodemographics including race/ethnicity, health literacy, and Spanish-language preference then conducted thematic analysis of focus group feedback.

RESULTS

Participants met in four virtual focus groups: adolescents from English-speaking households(n = 2), adolescents from Spanish-speaking households(n = 5), English-speaking parents(n = 4), and Spanish-speaking parents (n = 4). Five themes emerged: Parents (1) feared opioid use would result in overdose or addiction and (2) desired information about alternative medical and behavioral strategies to minimize use. (3) Parents felt empowered to manage their adolescent's opioid use and trusted their adolescent to prompt them for opioids. Adolescents trusted their parents to manage their opioid use but maintained their autonomy to limit opioid consumption when experiencing undesirable side effects. (4) Some adolescents and parents endorsed a preference for "not taking medication" in their households. (5) Both parents and adolescents reported previous knowledge of opioids prior to surgery, with adolescents learning more nuanced information about opioid safety after their surgeries.

CONCLUSIONS

Families feel empowered to manage their postoperative prescription opioid use but fear the negative effects of opioids and desire information on alternatives. Evidence-based, family-centric education from providers in a language preferred by the family could mitigate families' concerns and contribute to improved pain control and safety.

LEVEL OF EVIDENCE

IV.

Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study

OBJECTIVES

To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department.

STUDY DESIGN

This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations.

RESULTS

Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently.

CONCLUSIONS

Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.

A Risk Education Program Decreases Leftover Prescription Opioid Retention: An RCT

INTRODUCTION

Retaining leftover prescription opioids poses the risks of diversion, misuse, overdose, and death for youth and other family members. This study examined whether a new educational program would enhance risk perceptions and disposal intentions among parents and decrease their retention of leftover prescription opioids.

STUDY DESIGN

This study is an RCT (NCT03287622).

SETTING/PARTICIPANTS

A total of 648 parents whose children were prescribed opioid analgesics were recruited from a Midwestern, academic pediatric hospital between 2017 and 2019. Parents were randomized to receive routine information (control) with or without Scenario-Tailored Opioid Messaging Program intervention.

INTERVENTION

The intervention provided opioid risk and mitigation advice using interactive decisional feedback.

MAIN OUTCOME MEASURES

The main outcome measures were parents' perceptions of the riskiness of keeping/sharing opioids and child misuse measured at baseline, Days 3 and 14, their intention to dispose of leftover opioids, and their final retention decisions after the child's use (at or around Day 14).

RESULTS

Perceived riskiness of child misuse and keeping/sharing opioids increased from baseline through Day 14 only for parents in the intervention group (p≤0.006). However, there were no significant differences in risk perceptions between groups and no intervention effect on disposal intentions at either follow-up. Despite these findings, the intervention reduced the likelihood of parents' opioid retention when adjusted for important parent and child covariates (AOR=0.48; 95% CI=0.25, 0.93; p=0.028). Parents who reported past opioid misuse also showed higher retention behavior (AOR=4.78; 95% CI=2.05, 11.10; p<0.001).

CONCLUSIONS

A scenario-specific educational intervention emphasizing the potential risks that leftover opioids pose to children and that provided risk mitigation advice decreased parents' retention of their child's leftover opioid medication. Removing leftover prescription drugs from homes with children may be an important step to reducing diversion, accidental poisoning, and misuse among youth.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03287622.

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.

Using prescription opioids throughout a traumatic injury recovery: A qualitative exploratory study of adolescents in a Midwestern state

BACKGROUND

Injury is one of the most common reasons adolescents are prescribed opioids. Little is known about adolescent experiences who used prescription opioids throughout their recovery from traumatic injury.

METHODS

We used a qualitative exploratory study design nested within a longitudinal cohort study conducted at two trauma hospitals in the United States. We conducted semi-structured telephone interviews with adolescents (n = 28) aged from 12 to 20 years at the time of their hospital admission for injury. We used purposive sampling to gather a broad range of experiences from the longitudinal patient cohort. We conducted a modified thematic analysis of transcribed interviews.

RESULTS

Adolescents reported a wide range of efficacy with which prescription opioids controlled their pain during the injury recovery and numerous opioid-related side effects. A desire for relief from acute pain caused by the injury was the most common driver for using opioids in the hospital. At home, adolescents' decisions to use opioids were influenced by family history of addiction, awareness of harms associated with opioids, and desire to challenge themselves. Adolescents reported closely adhering to a prescribed regimen or using fewer opioids than prescribed while recovering at home. Finally, adolescents reported considerable variability in parental involvement in prescription opioid use, ranging from giving adolescents unrestricted access to prescription opioids to complete parental discretion and administration upon request.

CONCLUSIONS

Adolescents had diverse experiences with prescription opioids during recovery from traumatic injury. Educational interventions that focus on the appropriate use of opioids to address pain care needs among adolescents with traumatic injuries are urgently needed.

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.

To relieve pain or avoid opioid-related risk? A comparison of parents' analgesic trade-off preferences and decision-making in 2019 versus 2013 in a single U.S. pediatric hospital

BACKGROUND

Analgesic trade-off preferences, or the relative preference for pain relief vs. risk aversion, shape parents' decisions to give prescription opioids to their children. These preferences may be influenced by personal experiences and societal factors.

AIM

To examine whether parental analgesic trade-off preferences and opioid decision-making have shifted toward risk aversion during the opioid crisis in the United States.

METHODS

We conducted a secondary analysis of the preoperative survey data of parents from a single U.S. pediatric hospital whose children aged 5-17 years were to undergo painful surgery in 2013 (Time 1) or 2017/2019 (Time 2). Surveys assessed parents' analgesic trade-off preference (-12 or risk-averse to +12 or pain relief preferent, scores around 0=ambivalent) and their hypothetical decisions to give a prescribed opioid to a child in pain.

RESULTS

Data from 847 parents were included (Time 1, n = 361; Time 2, n = 486). Parents at Time 2 were significantly more risk-averse compared with Time 1 (adj.β: -0.84 [95% CI: -1.09, -0.60]). Parents at Time 2 were more than twice as likely to be risk-averse or ambivalent (OR: 2.17 [95% CI: 1.62, 2.91]). There was a significant interaction effect of Time*Preference on parents' decision to give the opioid (adj. OR: 1.09 [95% CI: 1.03, 1.16]). At Time 2, parents who were ambivalent or risk-averse were less likely than those who preferred to relieve pain to administer the prescribed opioid (OR: 0.57 [95% CI: 0.37, 0.89]). In contrast, there was no association between the preference group and the opioid decision at Time 1.

CONCLUSION

Findings suggest that parents of children scheduled for painful surgery at our pediatric hospital have become more analgesic risk-averse during the past decade. Parents' analgesic trade-off preferences may influence their decisions to administer prescribed opioids after surgery, which may contribute to children's pain outcomes.

Effect of a brief scenario-tailored educational program on parents' risk knowledge, perceptions, and decisions to administer prescribed opioids: a randomized controlled trial

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.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

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.

The relationship between parental factors, child symptom profile, and persistent postoperative pain interference and analgesic use in children

OBJECTIVES

Both parental and child factors have been previously associated with persistent or recurrent postoperative pain in children. Yet, little is known about the relative contribution of parent factors or whether child symptom factors might impact the association between parent factors and long-term pain. The aim of this study was to explore the associations between parent factors, child symptomology, and the child's long-term pain outcomes after surgery.

METHODS

This prospective, longitudinal study included parents and their children who were scheduled to undergo spinal fusion for underlying scoliosis. Parents completed baseline surveys about their pain history, pain relief preferences (ie, preference to relieve their child's pain vs avoid analgesic risks), and pain catastrophizing (ie, beliefs about their child's pain). Children were classified previously into high vs low symptom profiles at baseline based on their self-reported pain, catastrophizing, fatigue, depression, and anxiety. Children were assessed 1-year after surgery for their long-term pain interference scores and analgesic use. Serial regression modeling was used to explore whether associations between parent factors and the outcomes were changed when accounting for child factors.

RESULTS

Seventy-six parent/child dyads completed all surveys. Parental preferences and catastrophizing were atemporally associated with the child's baseline psychological-somatic symptom profile. Though parent and child factors were both associated with the long-term pain outcomes, when all three factors were accounted for, the associations between parent factors and long-term pain was fully attenuated by the child's profile.

DISCUSSION

These findings suggest that the relationship between parent factors and long-term postoperative pain outcomes may be dependent on the child's symptom profile at baseline. Since there may be bidirectional relationships between parent and child factors, interventions to mitigate long-term pain should address child symptoms as well as parental factors.

Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial

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.

Prescription Opioid Misuse Among Adolescents

Although recent spikes in overdose deaths are largely attributable to heroin and fentanyl, prescription opioids still account for a significant percentage of overdose deaths. Additionally, overdose deaths are not a problem solely for adults; roughly 8% of all overdose deaths occur in persons aged 15 to 24. In addition to identifying factors that increase risk for misuse and negative outcomes among adolescents, research must examine the causal mechanisms that link these factors to increased risk. Finally, the extant research must serve as the foundation for prevention/intervention strategies and identify treatments that are effective among adolescents with opioid use disorders.

Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children

Importance

Practice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced.

Objective

To assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids.

Design, Setting, and Participants

This cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children.

Main Outcomes and Measures

The percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids.

Results

Among 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications.

Conclusions and Relevance

These findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.

Postoperative pain: factors and tools to improve pain management in children

Outpatient surgery has made it increasingly common for parents to manage pain in the home setting. Studies have shown that parents often under treat pain, leaving children vulnerable to the negative side effects of suboptimal pain management. Multiple factors affect pain management like child’s age and developmental stage, language, cultural values like stoicism, parental beliefs about medication, biological differences among groups, etc. Understanding all the factors involved can help healthcare providers and parents better understand pain and contribute to optimal pain management. Multiple tools and technological interventions have been created to help create a better understanding of pain and a holistic approach to care.

An interactive web-based educational program improves prescription opioid risk knowledge and perceptions among parents

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.

Deliberative Prescription Opioid Misuse Among Adolescents andEmerging Adults: Opportunities for Targeted Interventions

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.