Refilling Opioid Prescriptions After Pediatric Orthopaedic Surgery: An Analysis of Incidence and Risk Factors

The influence of guidelines on opioid prescribing practices after pe-diatric anterior cruciate ligament reconstruction

OBJECTIVE

To report opioid prescription patterns after pediatric anterior cruciate ligament reconstruction (ACLR) and identify if the implementation of the opioid prescribing guidelines (OPGs) modified these patterns.

DESIGN

A retrospective chart review.

SETTING

Level 1 Pediatric Trauma Center.

PATIENTS

Pediatric patients who underwent primary ACLR at a single pediatric hospital system between the years 2016 and 2018 were included. Patients were excluded if they did not receive an opioid prescription from an orthopedic provider at the time of discharge or if they underwent an additional operative procedure within 90 days of the index surgery. Eighty-six patients met the criteria for a retrospective review.

INTERVENTIONS

Opioid prescriptions were converted into morphine equivalent doses (MEDs) for standardization.

MAIN OUTCOME MEASURE

The average MED prescribed at the time of discharge and during follow-up visits for pediatric patients undergoing ACLR.

RESULTS

Patient's age was the only independent variable that had a significant relationship with discharge MED (p = 0.002) and predicted that MED at discharge increases by 20.7 units [confidence interval = 12.3-29.1] for each increasing year in patient age. Discharge MED prescribed after implementation of the OPG was found to be significantly less than discharge MED prescribed prior to the OPG through Wilcoxon rank-sum test (p < 0.001).

CONCLUSIONS

Implementation of the OPG in Ohio led to a significant reduction in opioid doses prescribed to patients at all time points within 90 days of ACLR. However, these guidelines also led to a significant increase in the likelihood that post-OPG patients would receive an additional opioid prescription during follow-up within 90 days of surgery.

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

INTRODUCTION

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

AREAS COVERED

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

EXPERT OPINION

The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.

Factors Associated with Postoperative Opioid Use in Adolescents

BACKGROUND

We aimed to identify factors associated with postoperative prescription opioid use in adolescents.

METHODS

Adolescents aged 13-20 years undergoing surgery were prospectively recruited from a children's hospital. Adolescent-parent dyads completed a preoperative survey, measuring clinical and sociodemographic factors, and two postoperative surveys evaluating self-reported opioid use at 30- and 90-days. Poisson regression analysis identified factors associated with the number of pills used within 90-days, adjusting for age, gender, race/ethnicity, surgery type, and pain at discharge.

RESULTS

We enrolled 119 adolescents who reported postoperative opioid use following posterior spinal fusion (PSF) (50 %), arthroscopy (23 %), pectus excavatum repair (11 %), tonsillectomy (8 %), and hip reconstruction (7 %). Overall, 81 % of adolescents reported unused opioids. The median pain score at discharge was 7 (IQR:5-8). Adolescents reported using a median of 7 (IQR:2-15) opioid pills, with 20 (IQR:7-30) pills left unused. Compared to all other surgeries, adolescents undergoing PSF reported the highest median pill use (10, IQR:5-29; p = 0.004). Adolescents undergoing tonsillectomy reported the lowest median pill use (1, IQR:0-7; p = 0.03). On regression analysis, older patient age was associated with a 12 % increase in pill use (95 % CI:3%-23 %). Undergoing PSF was associated with a 63 % increase in pill use (95 % CI:15%-31 %). Each additional pain scale point reported at discharge was associated with a 13 % increase in pill use (95 % CI:5%-22 %).

CONCLUSIONS

Older age, surgery type, and patient-reported pain at discharge are associated with postoperative prescription opioid use in adolescents. Understanding patient and surgery-specific factors associated with opioid use may guide surgeons to minimize excess opioid prescribing.

LEVEL OF EVIDENCE

II.

Continuous Epidural Analgesia Versus Continuous Peripheral Nerve Block in Unilateral Lower Extremity Pediatric Orthopedic Surgery: A Matched Case Comparison Study

Introduction Continuous epidural analgesia (CEA) provides effective postoperative pain relief but includes a substantial side effect profile. Continuous peripheral nerve blocks (CPNBs) have fewer side effects and may quicken ambulation. The purpose of this study was to compare the morphine milligram equivalents (MMEs), need for analgesic rescue, visual analog scale (VAS) pain scores, time to ambulation, postoperative blood pressures, length of stay (LOS), and adverse event rates. Methods This was a matched case comparison study of pediatric patients (ages 8-17) undergoing unilateral lower limb surgery (41 CEA and 36 CPNB). Patients with a history of chronic pain, previous lower extremity surgery, and developmental delay were excluded. The Chi-square test and Student's t-test were used, and p-values < 0.05 were considered significant. Results There were no statistically significant differences in demographics or the American Society of Anesthesiologists (ASA) grade. There were no significant differences in postoperative MMEs, the need for analgesic rescue, or VAS scores on any postoperative day. The CEA group had a longer time to ambulation (2.56 ± 0.93 days versus 1.89 ± 0.69 days, p = 0.004). The CEA group demonstrated a higher number of days of systolic hypotension (0.61 ± 0.97 mmHg versus 0.06 ± 0.23 mmHg, p = 0.0009) and diastolic hypotension (1.90 ± 1.24 mmHg versus 1.00 ± 0.93 mmHg, p = 0.0006). There were no significant differences in the length of stay between the CEA and CPNB groups (5.08 versus 4.24, p = 0.28). There was no statistically significant difference between the rates of pruritus, light-headedness, and altered mental status. The CEA group demonstrated higher rates of nausea (51.2% versus 13.9%, p = 0.001), constipation (36.6% versus 8.3%, p = 0.004), urinary retention (9.8% versus 0%, p = 0.006), and average number of minor adverse events per patient (1.02 versus 0.25, p = 0.002). Conclusions CPNBs and CEAs demonstrate equivalent postoperative opioid use after unilateral lower extremity surgery in the pediatric population. In our population, a low complication rate and a decreased time to ambulation were seen in the CPNB group. There may be certain select scenarios priorly managed with a CEA that can be appropriately managed with a CPNB. A prospective multicenter study incorporating patient satisfaction data could further facilitate the incorporation of CPNB in pediatric pain management protocols after orthopedic surgery.

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.

What's New in Pain Management for Pediatric Orthopaedic Surgery

BACKGROUND

Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery.

METHODS

An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers.

RESULTS

A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions.

CONCLUSIONS

There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery.

LEVEL OF EVIDENCE

Level IV-literature review.