Pills, Polices, and Predicaments: The Unintended Consequences of a Health Care System's Policy toward Opioids

A government mandated consent safely reduces opioid utilization for major pediatric genitourinary surgeries

INTRODUCTION

We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries.

METHODS

All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data.

RESULTS

After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p<0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75)(p<0.001). The rate of delayed non-opioid analgesic prescriptions (6.6% vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%)(p = 0.809) remained unchanged. Data agreed with National Surgical Quality Improvement Program data in 98.5% of cases. After excluding one surgeon who departed after the transition period, regional block utilization did not change from 61/115(53%) to 147/320(45.9%)(p = 0.425).

CONCLUSIONS

A state mandated opioid consent safely reduced opioid utilization for most major pediatric genitourinary surgeries.

LEVEL OF EVIDENCE

Level III.

Opioid-prescribing patterns, storage, handling, and disposal in postoperative pediatric urology patients

BACKGROUND

Emerging research on surgeons and the opioid epidemic have focused on the adult population. Consequently, little is known regarding opioid-prescribing practices in the pediatric population. The goal of this study is to examine postoperative opioid-prescribing and consumption patterns, as well as storage and disposal trends for specific pediatric urologic procedures.

STUDY DESIGN

Patients undergoing surgery associated with specified Current Procedural Terminology codes were retrospectively identified, and details regarding opioid medications were obtained through our pharmacy database. Patients' guardians were contacted two weeks postoperatively to determine opioid usage. Opioids were prescribed at a standard dosing of 0.1 mg/kg per dose or the equivalent.

RESULTS

Of the 171 identified patients, 117 patients were successfully contacted, with 67 (39%) completing telephone surveys. The 3 most common pediatric urology procedures were inguinal hernia repair (N = 39), circumcision (N = 27), and cystoscopy (N = 16). Across all procedures, there was an average excess of 9.8 doses prescribed, corresponding to an overprescription rate of 64%. Of the patients prescribed opioids, 41 (62%) had leftover opioid medication two weeks postoperatively. Thirty-two of 41 (78%) patients did not dispose of their leftover medication. Only 13 patients received perioperative counseling on appropriate storage and disposal of opiates.

DISCUSSION

Prescribing practices for an array of pediatric urologic procedures are non-standardized and often generously excessive. We show universal overprescribing for all our reviewed urologic procedures. Sixty-two percent of pediatric urology patients did not use their entire prescribed opiate, leaving a significant pool of medicine within the pediatric family home. Given the low incidence of perioperative education, unsurprisingly a majority of our patients improperly handled and disposed off excess opioid medication.

CONCLUSION

There is general overprescription of postoperative opioids and poor perioperative opioid education in the pediatric urology population.

Exploring perceptions and experiences of patients who have chronic pain as state prescription opioid policies change: a qualitative study in Indiana

OBJECTIVES

The misuse and abuse of prescription opioids (POs) is an epidemic in the USA today. Many states have implemented legislation to curb the use of POs resulting from inappropriate prescribing. Indiana legislated opioid prescribing rules that went into effect in December 2013. The rules changed how chronic pain is managed by healthcare providers. This qualitative study aims to evaluate the impact of Indiana's opioid prescription legislation on the patient experiences around pain management.

SETTING

This is a qualitative study using interviews of patient and primary care providers to obtain triangulated data sources. The patients were recruited from an integrated pain clinic to which chronic pain patients were referred from federally qualified health clinics (FQHCs). The primacy care providers were recruited from the same FQHCs. The study used inductive, emergent thematic analysis.

PARTICIPANTS

Nine patient participants and five primary care providers were included in the study.

RESULTS

Living with chronic pain is disruptive to patients' lives on multiple dimensions. The established pain management practices were disrupted by the change in prescription rules. Patient-provider relationships, which involve power dynamics and decision making, shifted significantly in parallel to the rule change.

CONCLUSIONS

As a result of the changes in pain management practice, some patients experienced significant challenges. Further studies into the magnitude of this change are necessary. In addition, exploring methods for regulating prescribing while assuring adequate access to pain management is crucial.

Targeting practitioners: A review of guidelines, training, and policy in pain management

This paper reviews the current literature on clinical guidelines, practitioner training, and government/payer policies that have come forth in response to the national rise in prescription opioid overdoses. A review of clinical opioid prescribing guidelines highlights the need for more research on safe and effective treatment options for chronic pain, improved guidance for the best management of post-operative pain, and evaluation of the implementation and impact of guideline recommendations on patient risk and outcomes. Although there is increasing attention to training in pain management in medical schools and medical residency programs, educational opportunities remain highly variable, and the need for additional clinician training in the recognition and treatment of pain as well as opioid use disorder has been recognized. Mandated use of private, federal and state educational and clinical initiatives such as Risk Evaluation and Mitigation Strategies (REMS) and Prescription Drug Monitoring Programs (PDMPs) generally increase utilization of these initiatives, but more research is needed to determine the impact of these initiatives on provider behaviors, treatment access, and patient outcomes. Finally, there is an acute need for more research on safe and effective treatments for chronic pain as well as an increased multi-level focus on improving training and access to evidence-based treatment for opioid use disorder as well as non-pharmacologic and non-interventional chronic pain treatments, so that these guideline-recommended interventions can become mainstream, accessible, first-line interventions for chronic pain and/or opioid use disorders.

Critical appraisal of extended-release hydrocodone for chronic pain: patient considerations

Opioid analgesics are currently the most effective pharmacologic option for the management of both acute and chronic forms of moderate-to-severe pain. Although the "as-needed" use of immediate-release formulations is considered optimum for treating acute, painful episodes of limited duration, the scheduled dosing of extended-release formulations with immediate-release supplementation for breakthrough pain is regarded to be most effective for managing chronic conditions requiring around-the-clock treatment. The recent introduction of extended-release formulations of the opioid analgesic hydrocodone potentially broadened the possibility of providing pain relief for individuals for whom current formulations are either ineffective or not tolerated. However, reaction to the approval of the new formulations has fueled controversy over the general safety and need for opioid medications, in light of their potential for misuse, abuse, diversion, and addiction. Here, we discuss how the approval of extended-release formulations of hydrocodone and the emotionally charged controversy over their release may affect physician prescribing and the care available to patients in need of chronic opioid therapy for the management of pain.