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Odegard MN, Ceasar RC, Hijaz D, Obinelo A, Rosales A, Bhanvadia S, Kirkpatrick M, Kim E, Kelley-Quon LI. Adolescent and Parent Perceptions of Postoperative Opioid Use: A Qualitative, Thematic Analysis. J Pediatr Surg 2024; 59:718-724. [PMID: 38184435 DOI: 10.1016/j.jpedsurg.2023.12.015] [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: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
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.
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Affiliation(s)
- Marjorie N Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA.
| | - Rachel Carmen Ceasar
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, 1845 N Soto St, Los Angeles, CA 90032, USA
| | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Adaeze Obinelo
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Alvina Rosales
- Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA; Division of Pain Medicine, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA; Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Sumeet Bhanvadia
- Aresty Department of Urology, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Matthew Kirkpatrick
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, 1845 N Soto St, Los Angeles, CA 90032, USA; Department of Psychology, Dornsife College of Letters, Art and Sciences, University of Southern California, 3620 South McClintock Ave, Los Angeles, CA 90089, USA
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA; Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, 1845 N Soto St, Los Angeles, CA 90032, USA
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Ali S, Dworsky-Fried Z, Moir M, Bharadia M, Rajagopal M, Gouin S, Sawyer S, Pellerin S, Bourrier L, Poonai N, Stang A, Leung J, van Manen M. Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study. J Pediatr 2023; 258:113405. [PMID: 37023945 DOI: 10.1016/j.jpeds.2023.113405] [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: 12/18/2022] [Revised: 03/05/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
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.
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Affiliation(s)
- Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Women and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Zoë Dworsky-Fried
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mackenzie Moir
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Manisha Bharadia
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Manasi Rajagopal
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Serge Gouin
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Scott Sawyer
- Departments of Pediatrics and Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephanie Pellerin
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Lise Bourrier
- Departments of Pediatrics and Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Antonia Stang
- Department of Pediatrics, Cummings School of Medicine, University of Calgary
| | - Julie Leung
- PEAK Research Team Family Representative, Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael van Manen
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Women and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
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Voepel-Lewis T, Boyd CJ, Tait AR, McCabe SE, Zikmund-Fisher BJ. A Risk Education Program Decreases Leftover Prescription Opioid Retention: An RCT. Am J Prev Med 2022; 63:564-573. [PMID: 35909029 PMCID: PMC10866200 DOI: 10.1016/j.amepre.2022.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/14/2022] [Accepted: 04/22/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Terri Voepel-Lewis
- School of Nursing, University of Michigan, Ann Arbor, Michigan; Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Center for the Study of Drugs, Alcohol, Smoking and Health (DASH Center), University of Michigan, Ann Arbor, Michigan.
| | - Carol J Boyd
- School of Nursing, University of Michigan, Ann Arbor, Michigan; Center for the Study of Drugs, Alcohol, Smoking and Health (DASH Center), University of Michigan, Ann Arbor, Michigan
| | - Alan R Tait
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sean Esteban McCabe
- School of Nursing, University of Michigan, Ann Arbor, Michigan; Center for the Study of Drugs, Alcohol, Smoking and Health (DASH Center), University of Michigan, Ann Arbor, Michigan; Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Brian J Zikmund-Fisher
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan; Department of Health Behavior Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan; Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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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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Mazurenko O, Mills CA, Bandali E, Ballard JH, Bell TM. Using prescription opioids throughout a traumatic injury recovery: A qualitative exploratory study of adolescents in a Midwestern state. Drug Alcohol Depend 2022; 236:109480. [PMID: 35525239 DOI: 10.1016/j.drugalcdep.2022.109480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Olena Mazurenko
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, 1050 Wishard Blvd, RG 6140, Indianapolis, IN 46202, United States.
| | - Carol A Mills
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, United States.
| | - Elhaam Bandali
- Program Management Specialist, Center for Health Policy, Indiana University Richard M. Fairbanks School of Public Health, United States.
| | - Joseph H Ballard
- Medical Student, Indiana University School of Medicine, United States.
| | - Teresa M Bell
- Trauma Research Director, Intermountain Primary Children's Hospital, United States; Depts of Surgery and Population Health Sciences at University of Utah School of Medicine, Intermountain Primary Children's Hospital, United States.
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Hedges EA, Livingston MH, Esce A, Browne M, Moriarty KP, Raval MV, Rothstein DH, Wakeman D. Post-Procedural Opioid Prescribing in Children: A Survey of the American Academy of Pediatrics. J Surg Res 2021; 269:1-10. [PMID: 34507081 DOI: 10.1016/j.jss.2021.07.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/08/2021] [Accepted: 07/20/2021] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Elizabeth A Hedges
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Michael H Livingston
- Division of Pediatric Surgery, Department of Surgery, University of Rochester, Golisano Children's Hospital, Rochester, New York
| | - Antoinette Esce
- Division of Otolaryngology Head and Neck Surgery, Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Marybeth Browne
- Division of Pediatric Surgical Specialties, Department of Surgery, Lehigh Valley Reilly Children's Hospital, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Kevin P Moriarty
- Division of Pediatric Surgery, Baystate Children's Hospital, University of Massachusetts Medical School-Baystate, Springfield, Maryland
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David H Rothstein
- Pediatric General and Thoracic Surgery, Seattle Children's Hospital; Department of Surgery, University of Washington, Seattle, Washington
| | - Derek Wakeman
- Division of Pediatric Surgery, Department of Surgery, University of Rochester, Golisano Children's Hospital, Rochester, New York
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Lenko R, Voepel-Lewis T. 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. Paediatr Anaesth 2021; 31:878-884. [PMID: 34008280 PMCID: PMC8721525 DOI: 10.1111/pan.14209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/23/2021] [Accepted: 05/10/2021] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Rachel Lenko
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Terri Voepel-Lewis
- University of Michigan School of Nursing, Ann Arbor, Michigan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
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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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Siemer LC, Foxen-Craft E, Malviya S, Ramirez M, Li GY, James C, Voepel-Lewis T. The relationship between parental factors, child symptom profile, and persistent postoperative pain interference and analgesic use in children. Paediatr Anaesth 2020; 30:1340-1347. [PMID: 33010105 DOI: 10.1111/pan.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Lauren C Siemer
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Emily Foxen-Craft
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Shobha Malviya
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mark Ramirez
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - G Ying Li
- Department of Orthopedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Chrystina James
- Department of Orthopedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Terri Voepel-Lewis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,School of Nursing, University of Michigan, Ann Arbor, MI, USA
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11
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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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12
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Abstract
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.
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13
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Chua KP, Harbaugh CM, Brummett CM, Bohm LA, Cooper KA, Thatcher AL, Brenner MJ. Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children. JAMA Otolaryngol Head Neck Surg 2019; 145:911-918. [PMID: 31393537 DOI: 10.1001/jamaoto.2019.2107] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
| | - Calista M Harbaugh
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor.,Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Lauren A Bohm
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Karen A Cooper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Aaron L Thatcher
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
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14
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Makhlouf MM, Garibay ER, Jenkins BN, Kain ZN, Fortier MA. Postoperative pain: factors and tools to improve pain management in children. Pain Manag 2019; 9:389-397. [DOI: 10.2217/pmt-2018-0079] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Mai M Makhlouf
- Center on Stress & Health, University of California Irvine, Irvine, CA 92697 USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA 92868 USA
| | - Eric Robles Garibay
- Center on Stress & Health, University of California Irvine, Irvine, CA 92697 USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA 92868 USA
| | - Brooke N Jenkins
- Center on Stress & Health, University of California Irvine, Irvine, CA 92697 USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA 92868 USA
- Department of Psychology, Chapman University, Orange, CA 92866
| | - Zeev N Kain
- Center on Stress & Health, University of California Irvine, Irvine, CA 92697 USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA 92868 USA
- Yale Child Study Center, Yale University, New Haven, CT 06519 USA
| | - Michelle A Fortier
- Center on Stress & Health, University of California Irvine, Irvine, CA 92697 USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Orange, CA 92868 USA
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA 92697
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15
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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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16
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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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