Opioid Prescribing for the Treatment of Acute Pain in Children on Hospital Discharge

A Double-blinded Randomized Controlled Trial Assessing the Efficacy of Opioid Disposal Instructions with Parental Education on Proper Opioid Disposal Rates Following Ambulatory Pediatric Urologic Surgery

OBJECTIVES

To determine if the administration of standardized opioid disposal instructions with focused parental education improves proper disposal of leftover opioid medication among families of children undergoing ambulatory urologic surgery compared to routine postoperative instructions.

METHODS

A prospective, double-blinded, single-center randomized controlled trial was conducted in children 6-18 years undergoing ambulatory urology procedures between October 2021 and April 2023. Patients were randomized (1:1) to receive either the Food and Drug Administration (FDA) opioid disposal best practices worksheet plus nursing parental education or routine postoperative instructions alone. All patients were prescribed acetaminophen and ibuprofen and a per-protocol rescue opioid prescription. The primary outcome was rate of proper opioid disposal at 10-14 days post-procedure. Secondary outcomes included parents' postoperative pain measure (PPPM) scores, numerical pain scale (NPS) scores, and weight-based opioid utilization at 48 hours and 10-14 days.

RESULTS

We randomized 104 participants (53 intervention, 51 control) with 97% (101/104) complete follow-up data at 10-14 days. Patient demographics, procedural characteristics, and analgesia use were similar between groups. We observed no significant difference in proper opioid disposal rates between arms (31% intervention vs 18% control; estimated difference in proportion 13% [95% CI, -4%-29%]; P = .1). There were no increased odds of proper disposal of leftover opioid medication at 10-14 days with the intervention compared to the control (OR 2.0 [95% CI 0.8-5.1]; P = .1). We observed no differences in PPPM scores, NPS scores, or opioid utilization at 48 hours or 10-14 days.

CONCLUSION

Providing formal opioid disposal instructions with parental education did not improve proper disposal of leftover opioid medication nor did it alter post-discharge opioid utilization after pediatric urologic surgery.

Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline

This is the first clinical practice guideline (CPG) from the American Academy of Pediatrics outlining evidence-based approaches to safely prescribing opioids for acute pain in outpatient settings. The central goal is to aid clinicians in understanding when opioids may be indicated to treat acute pain in children and adolescents and how to minimize risks (including opioid use disorder, poisoning, and overdose). The document also seeks to alleviate disparate pain treatment of Black, Hispanic, and American Indian/Alaska Native children and adolescents, who receive pain management that is less adequate and less timely than that provided to white individuals. There may also be disparities in pain treatment based on language, socioeconomic status, geographic location, and other factors, which are discussed. The document recommends that clinicians treat acute pain using a multimodal approach that includes the appropriate use of nonpharmacologic therapies, nonopioid medications, and, when needed, opioid medications. Opioids should not be prescribed as monotherapy for children or adolescents who have acute pain. When using opioids for acute pain management, clinicians should prescribe immediate-release opioid formulations, start with the lowest age- and weight-appropriate doses, and provide an initial supply of 5 or fewer days, unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days. Clinicians should not prescribe codeine or tramadol for patients younger than 12 years; adolescents 12 to 18 years of age who have obesity, obstructive sleep apnea, or severe lung disease; to treat postsurgical pain after tonsillectomy or adenoidectomy in patients younger than 18 years; or for any breastfeeding patient. The CPG recommends providing opioids when appropriate for treating acutely worsened pain in children and adolescents who have a history of chronic pain; clinicians should partner with other opioid-prescribing clinicians involved in the patient's care and/or a specialist in chronic pain or palliative care to determine an appropriate treatment plan. Caution should be used when treating acute pain in those who are taking sedating medications. The CPG describes potential harms of discontinuing or rapidly tapering opioids in individuals who have been on stable, long-term opioids to treat chronic pain. The guideline also recommends providing naloxone and information on naloxone, safe storage and disposal of opioids, and direct observation of medication administration. Clinicians are encouraged to help caregivers develop a plan for safe disposal. The CPG contains 12 key action statements based on evidence from randomized controlled trials, high-quality observational studies, and, when studies are lacking or could not feasibly or ethically be conducted, from expert opinion. Each key action statement includes a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Single-dose Intraoperative Methadone for Pain Management in Pediatric Tonsillectomy: A Randomized Double-blind Clinical Trial

BACKGROUND

More than 500,000 elective tonsillectomies are performed in U.S. children annually. Pain after pediatric tonsillectomy is common, often severe, and undertreated. There is no consensus on the optimal management of perioperative tonsillectomy pain. Methadone, with an elimination half-life of 1 to 2 days, has a longer duration of effect than short-duration opioids such as fentanyl. The primary objective of this study was to investigate the intraoperative use of methadone for pediatric tonsillectomy. It tested the hypothesis that methadone would result in less postoperative opioid use compared with short-duration opioids in children after tonsillectomy.

METHODS

This double-blind, randomized, parallel group trial in children (3 to 17 yr) undergoing tonsillectomy compared single-dose intravenous methadone (0.1 mg/kg then 0.15 mg/kg age-ideal body weight, in a dose escalation paradigm) versus as-needed short-duration opioid (fentanyl) controls. Opioid use, pain, and side effects were assessed in-hospital and 7 days postoperatively via electronic surveys. The primary outcome was total 7-day opioid use in oral morphine equivalents per kilogram (kg). Secondary outcomes were opioid use in the postanesthesia care unit, daily pain scores, and total number of 7-day opioid doses used.

RESULTS

Data analysis included 60 children (20/group), age 5.9 ± 3.7 yr (mean ± SD; median, 4; range, 3 to 17). Total 7-day opioid use (oral morphine equivalents per kg median [interquartile range]) was 1.5 [1.2, 2.1] in controls, 0.9 [0.1, 1.4] after methadone 0.1 mg/kg (P = 0.045), and 0.5 [0, 1.4] after methadone 0.15 mg/kg (P = 0.023). Postanesthesia care unit opioid use (oral morphine equivalents per kg) in controls was 0.15 [0.1, 0.3], 0.04 [0, 0.1] after methadone 0.1 mg/kg (P = 0.061). and 0.0 [0, 0.1] after methadone 0.15 mg/kg (P = 0.021). Postoperative pain scores were not different between groups. No serious opioid-related adverse events occurred.

CONCLUSIONS

This small initial study in children undergoing tonsillectomy found that single-dose intraoperative methadone at 0.15 mg/kg age ideal body weight was opioid-sparing compared with intermittent fentanyl.

EDITOR’S PERSPECTIVE

Association of Opioid Disposal Practices with Parental Education and a Home Opioid Disposal Kit Following Pediatric Ambulatory Surgery

BACKGROUND

The majority of opioid analgesics prescribed for pain after ambulatory pediatric surgery remain unused. Most parents do not dispose of these leftover opioids or dispose of them in an unsafe manner. We aimed to evaluate the association of optimal opioid disposal with a multidisciplinary quality improvement (QI) initiative that proactively educated parents about the importance of optimal opioid disposal practices and provided a home opioid disposal kit before discharge after pediatric ambulatory surgery.

METHODS

Opioid disposal behaviors were assessed during a brief telephone interview pre- (Phase I) and post-implementation (Phase II) after surgery. For each phase, we aimed to contact the parents of 300 pediatric patients ages 0 to 17 years who were prescribed an opioid after an ambulatory surgery. The QI initiative included enhanced education and a home opioid disposal kit including DisposeRX®, a medication disposal packet that renders medications inert within a polymeric gel when mixed with water. Weighted segmented regression models evaluated the association between the QI initiative and outcomes. We considered the association between the QI initiative and outcome significant if the beta coefficient for the change in intercept between the end of Phase I and the beginning of Phase II was significant. Safe opioid disposal and any opioid disposal were evaluated as secondary outcomes.

RESULTS

The analyzed sample contained 161 pediatric patients in Phase I and 190 pediatric patients in Phase II. Phase II (post-QI initiative) cohort compared to Phase I cohort reported higher rates of optimal (58%, n = 111/190 vs 11%, n = 18/161) and safe (66%, n = 125/190 vs 34%, n = 55/161) opioid disposal. Weighted segmented regression analyses demonstrated significant increases in the odds of optimal (odds ratio [OR], 26.5, 95% confidence interval [CI], 4.0-177.0) and safe (OR, 4.4, 95% CI, 1.1-18.4) opioid disposal at the beginning of Phase II compared to the end of Phase I. The trends over time (slopes) within phases were nonsignificant and close to 0. The numbers needed to be exposed to achieve one new disposal event were 2.2 (95% CI, 1.4-3.7]), 3.1 (95% CI, 1.6-7.4), and 4.3 (95% CI, 1.7-13.6) for optimal, safe, and any disposal, respectively.

CONCLUSIONS

A multidisciplinary approach to educating parents on the importance of safe disposal of leftover opioids paired with dispensing a convenient opioid disposal kit was associated with increased odds of optimal opioid disposal.

Persistent Opioid Use Following Pediatric Nonfatal Firearm Injury

OBJECTIVE

Firearms are a major cause of pediatric injury. An analysis of opioid use following pediatric firearm injury has not previously been reported. Our objective was to determine the prevalence and factors associated with persistent opioid use among pediatric nonfatal firearm injury victims.

METHODS

We performed a retrospective cohort study using 2015-18 claims data from the Merative MarketScan Multi-State Medicaid and Commercial Databases, utilizing International Classification of Diseases, Tenth Revision codes for firearm injury and National Drug Codes for opioids. Dispensed opioid claims were used as a proxy for opioid use. Opioid exposure was defined both dichotomously and continuously (by the total number of opioid days prescribed) in the 30 days following discharge from firearm injury index encounter. Persistent opioid use was defined as ≥1 opioid claim(s) in the 90 to 270 days following index encounter. Multivariable logistic regression analysis was performed to determine whether covariates of interest were associated with greater odds of persistent opioid use.

RESULTS

Our cohort consisted of 2110 children who experienced nonfatal firearm injury (mean age 13.5, 80.9% male, 79.5% Medicaid) with 608 children (28.8%) exposed to opioids. Of patients exposed to opioids, 10.4% developed persistent opioid use. In adjusted analyses, each opioid day dispensed during the exposure period represented 5% greater odds of experiencing persistent opioid use.

CONCLUSIONS

Clinicians caring for children injured by firearms should be aware of the risk of developing persistent opioid use and balance that risk with the need to sufficiently control pain.

Sociodemographic differences in opioid use and recovery following ambulatory pediatric urologic procedures

Our aim was to examine associations between sociodemographic factors and postoperative opioid use and recovery among pediatric patients undergoing outpatient urologic procedures. We retrospectively evaluated 831 patients undergoing ambulatory urologic procedures from 2013 to 2017 at an urban pediatric hospital. Patients were evaluated for days of opioid use and days until return to baseline behavior. Differences in outcomes by race/ethnicity, primary language, median neighborhood household income, and health insurance type were analyzed using negative binomial regression models. Overall, patients reported a median of 1.0 day (IQR: 2.0) of postoperative opioid use and 3.0 days (IQR: 6.0) of recovery time. After controlling for covariates, patients with non-English speaking parents took opioids for 26.5% (95% CI: 11.4-41.7%) longer and had 27.8% (95% CI: 8.1-51.0%) longer recovery time than patients with English-speaking parents. Hispanic patients took opioids for 27.5% (95% CI: 0.1-54.9%) longer than White patients. Patients with public insurance used opioids for 47.6% (95% CI: 5.0-107.4%) longer than privately insured patients. Non-English speaking, Hispanic, and publicly insured patients had a longer duration of postoperative opioid use than primarily English-speaking, White, and privately insured patients, respectively. Identifying these disparities is important for designing equitable postoperative care pathways.

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.

Opioid Utilization after Cardiac Surgery in the Pediatric Medicaid-Insured Population

OBJECTIVE

To determine the variation of outpatient opioid prescribing across the US in postoperative pediatric cardiac patients.

STUDY DESIGN

Retrospective, cross-sectional study using a concatenated database of Medicaid claims between from 2016 through 2018 of children 0-17 years, discharged after cardiac surgery and receiving an opioid prescription within 30 days. Filled prescriptions were identified and converted to morphine milligram equivalents (MME). Use, duration, and dose were analyzed by sex, race, ethnicity, residence urbanicity, and region.

RESULTS

Among 17 186 Medicaid-enrolled children after cardiac surgery, 2129 received opioids within 30 days of discharge. Females received lower doses than males (coefficient -0.17, P = .022). Hispanic individuals were less likely to receive opioids (coefficient 0.53, P < .05, 95% CI: 0.38-0.71) and for shorter periods (coefficient 0.83, P < .001). Midwest (MW) (OR 0.61, 95% P-values < 0.05, 95% CI: 0.46-0.80) and Northeast (NE) (OR 0.43, 95% P-values < 0.05, 95% CI: 0.30-0.61) regions were less likely to receive opioids but used higher doses compared with the Southeast (SE) (MW coefficient 0.41, Southwest (SW) coefficient 0.18, NE coefficient 0.32, West (W) coefficient 0.19, P < .05).

CONCLUSIONS

There were significant variations in opioid prescribing after cardiac surgery by race, ethnicity, sex, and region. National guidelines for outpatient use of opioids in children after cardiac surgery may help limit practice variation and reduce potential harms in outpatient opioid usage.

Pain during the first year after scoliosis surgery in adolescents, an exploratory, prospective cohort study

Objective

Approximately 50% of adolescents who have undergone scoliosis surgery still experience severe pain one year postoperatively. We explored the postoperative pain trajectory and the potential value of preoperative Thermal Quantitative Sensory Testing (T-QST) as predictor of chronic postsurgical pain after scoliosis surgery.

Design

Single-center prospective cohort study in adolescents undergoing scoliosis surgery.

Outcomes

Prevalence of chronic postsurgical pain (CPSP) one year after scoliosis surgery and postsurgical pain course during this year. The need for rescue medication and the relationship between pre-operative T-QST, acute pain and CPSP.

Results

Thirty-nine patients (mean age 13.9 years; SD 1.9 years) completed the study. One year postoperatively, ten patients (26%) self-reported pain [numeric rating scale (NRS) score ≥ 4]) when moving and two (5%) when in rest. Four of these patients (10.3%) experienced neuropathic pain. The pre-operative cold pain threshold was lower (p = 0.002) in patients with CPSP at 12 months. Preoperative cold and heat pain thresholds were correlated with the number of moderate or severe pain reports (NRS ≥ 4) in the first week postoperatively (r -.426; p = 0.009 and r.392; p = 0.016, respectively).

Conclusions

One year after scoliosis surgery, a significant part of patients (26%) still reported pain, some with neuropathic characteristics. Better diagnosis and treatment is needed; our study suggests that T-QST could be further explored to better understand and treat children with this negative outcome.

Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients

INTRODUCTION

Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution.

METHODS

We identified pediatric patients (ages below 18 y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships.

RESULTS

Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types ( P =0.036). Higher BMI was positively correlated with more prescribed opioid doses ( R2 =0.647, P <0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10.

CONCLUSIONS

We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery

Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.

Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study

INTRODUCTION

Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention.

METHODS

Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability.

RESULTS

Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730).

CONCLUSIONS

The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair

OBJECTIVE

Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population.

DESIGN

A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty.

SETTING

New York-Presbyterian Hospital.

PATIENTS/PARTICIPANTS

Patients with cleft palate undergoing primary palatoplasty.

INTERVENTIONS

Meta-analysis of reported patient outcomes in ERAS and control cohorts.

MAIN OUTCOME MEASURE(S)

Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications.

RESULTS

Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls (P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients (P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups (P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses.

CONCLUSIONS

ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

Opioid stewardship and perioperative management of pediatric tympanoplasty

OBJECTIVE

To provide insight into the intraoperative management, admission course, pain management, and graft success of microscope- and endoscope-assisted tympanoplasty.

STUDY DESIGN

Retrospective Chart Review.

METHODS

This study included children 18 years and younger who underwent ambulatory tympanoplasty at a tertiary pediatric hospital between January 2018 and December 2020. Medical records were reviewed and information about intraoperative factors, surgical approach, laterality, complications, and post-operative perforation closure success rates was collected. Multivariate analysis was performed to compare and contrast the two surgical approaches.

RESULTS

The review included 321 pediatric patients who underwent a tympanoplasty. Endoscopic tympanoplasty accounted for 17.4%, while microscopic tympanoplasty accounted for 82.6%. In both approaches, the rate of intraoperative complications, postoperative complications, audiological improvements, and perforation closure success rates were statistically similar. However, patients who underwent endoscopic tympanoplasty were 3.96 times less likely to require opioids in the post-anesthesia care unit (PACU) and had a shorter post-operative admission length. This pattern emerged regardless of the type of graft used. Obtaining an autograft was not associated with a higher opioid requirement in the PACU.

CONCLUSION

While both approaches are viable, our findings demonstrate the reduced need for opioids with similar success rates following an endoscopic tympanoplasty. Ultimately, the trade-off for the minimally invasive endoscopic approach appears to be a less painful experience for the child while promoting clinically appropriate opioid stewardship in the perioperative setting.

Impact of state legislation and institutional protocols on opioid prescribing practices following pediatric tonsillectomy

Objectives

Tonsillectomy is a common pediatric surgery, and pain is an important consideration in recovery. Due to the opioid epidemic, individual states, medical societies, and institutions have all taken steps to limit postoperative opioids, yet few studies have examined the effect of these interventions on pediatric otolaryngology practices. The primary aim of this study was to characterize opioid prescribing practices following North Carolina state opioid legislation and targeted institutional changes.

Methods

This single center retrospective cohort study included 1552 pediatric tonsillectomy patient records from 2014 to 2021. The primary outcome was number of oxycodone doses per prescription. This outcome was assessed over three time periods: (1) Before 2018 North Carolina opioid legislation. (2) Following legislation, before institutional changes. (3) After institutional opioid-specific protocols.

Results

The mean (± standard deviation) number of doses per prescription in Periods 1, 2, and 3 was: 58 ± 53, range 4-493; 28 ± 36, range 3-488; and 23 ± 17, range 1-139, respectively. In the adjusted model, Periods 2 and 3 had lower doses by -41% (95% CI -49%, -32%) and -40% (95% CI -55%, -19%) compared to Period 1. After 2018 North Carolina legislation, dosage decreased by -9% (95% CI -13%, -5%) per year. Despite interventions, ongoing variability in prescription regimens remained in all periods.

Conclusion

Legislative and institution specific opioid interventions was associated with a 40% decrease in oxycodone doses per prescription following pediatric tonsillectomy. While variability in opioid practices decreased post-interventions, it was not eliminated.

Level of evidence

3.

Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020

Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.

Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery

INTRODUCTION

There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery.

METHODS

Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression.

RESULTS

Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions.

DISCUSSION/CONCLUSION

Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction.

LEVELS OF EVIDENCE

Level III.

Association Between Initial Opioid Prescription Duration and 30-Day Risk of Receiving Repeat Opioid Among Children

OBJECTIVE

Our study evaluated the association between initial opioid prescription duration and receipt of a repeat opioid prescription in children.

METHODS

Eligible individuals were children between 1 and 17 years of age who enrolled in a Medicaid Managed Care plan and filled an incident opioid prescription during 2013 to 2018. An incident prescription was defined as receipt of an opioid analgesic without a prior use for 12 months. A repeat opioid prescription was defined as receipt of a subsequent opioid prescription within 30 days since the end of incident opioid prescription. A hierarchical multivariable logistic regression model was fitted to test the association between incident opioid prescription duration and the likelihood of receiving a repeat prescription.

RESULTS

The cohort consisted of 17,086 children receiving an incident opioid prescription in which 6272 (36.7%) received 1 to 3 days' supply, 8442 (49.4%) received 4 to 7 days' supply, 1434 (8.4%) received 8 to 10 days' supply, and 938 (5.5%) received >10 days' supply. Of these incident opioid recipients, 1780 (10.4%) filled a repeat opioid prescription. The multilevel model results indicated that, children receiving 4 to 7 days' supply (adjusted odds ratio [aOR]: 0.98 {0.9-1.1}), 8 to 10 days' supply (aOR: 1.03 [0.8-1.3]), and >10 days' supply (aOR: 0.85 [0.7-1.1]) had comparable likelihoods of receiving a repeat prescription as those receiving 1 to 3 days' supply.

DISCUSSION

Nearly 10% of children who filled an opioid prescription for acute pain received a repeat prescription. Initial prescription duration was not associated with the risk of receiving a repeat prescription.

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

BACKGROUND

Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.

METHODS

A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus.

RESULTS

60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.

CONCLUSIONS

Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

A Novel Tool to Predict Postoperative Opioid Need after Laparoscopic Appendectomy in Children: A Step toward Evidence-Based Pain Management

BACKGROUND

 Optimizing postoperative pain treatment is essential to minimize morbidity, lower costs, and ensure patient and parent satisfaction. This study aims at identifying pre- and intraoperative parameters predicting opioid needs after laparoscopic appendectomy to enable timely and adequate postoperative pain control.

MATERIALS AND METHODS

 A retrospective analysis of patients treated with laparoscopic appendectomy for appendicitis between January 2018 and March 2019 was performed. Multiple logistic regression was applied to identify predictors of opioid demand.

RESULTS

 Based on our analysis, we developed a prediction tool for opioid requirements after laparoscopic appendectomies in children. The integrated parameters are: presence of turbid fluid, age, white-blood-cell count, symptom duration, and body temperature.

CONCLUSION

 We developed an algorithm-based predictor tool that has the potential to better anticipate postoperative pain and, thereby, optimize pain management following laparoscopic appendectomies in children. The proposed predictor tool will need validation through further prospective studies.

Factors Associated With Safe Prescription Opioid Disposal After Surgery in Adolescents

INTRODUCTION

Unused prescription opioids contribute to diversion, unintended exposure, and poisonings in adolescents. Factors associated with safe prescription opioid disposal for adolescents undergoing surgery are unknown.

METHODS

Parents of adolescents (13-20 y) undergoing surgery associated with an opioid prescription were enrolled preoperatively. Parents completed a baseline survey measuring sociodemographics and family history of substance abuse and two postoperative surveys capturing opioid use and disposal at 30 and 90 d. Safe disposal was defined as returning opioids to a healthcare facility, pharmacy, take-back event, or a police station. Factors associated with safe opioid disposal were assessed using bivariate analysis.

RESULTS

Of 119 parent-adolescent dyads, 90 (76%) reported unused opioids after surgery. The majority of parents reporting unused opioids completed the surveys in English (80%), although many (44%) spoke another language at home. Most reported income levels <$60,000 (54%), did not attend college (69%), and had adequate health literacy (66%). Most parents (78%) did not report safe opioid disposal. Safe opioid disposal was associated with younger patient age, (median 14 y, IQR 13-16.5 versus median 15.5 y, IQR 14-17, P = 0.031), fewer days taking opioids (median 5, IQR 2-6 versus median 7, IQR 4-14, P = 0.048), and more leftover pills (median 20, IQR 10-35 versus median 10, IQR 5-22, P = 0.008).

CONCLUSIONS

Most parents fail to safely dispose of unused opioids after their adolescent's surgery. Younger patient age, shorter duration of opioid use, and higher number of unused pills were associated with safe disposal. Interventions to optimize prescribing and educate parents about safe opioid disposal are warranted.

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.

Opioid Prescribing Trends After Major Pediatric Ear Surgery: A 12-Year Analysis

OBJECTIVE

Postoperative opioid prescriptions tend to exceed children's analgesic needs, but awareness of the opioid epidemic may have driven changes in prescribing behaviors. This study evaluated opioid prescribing patterns after major pediatric ear surgery.

METHODS

This study reviewed all cases of tympanoplasty, tympanomastoidectomy, mastoidectomy, cochlear implantation, otoplasty, and aural atresia repair at a pediatric hospital during 2010-2021. Regressions were conducted to identify opioid prescribing trends over time. Potential covariates were assessed. Returns to the system were reviewed as a balancing measure.

RESULTS

Even without a targeted protocol, opioid prescribing declined significantly. After prescribing peaked in 2012-2013, significant negative trends yielded lower rates of opioid prescriptions, fewer doses per prescription, smaller patient-weight-standardized dose sizes, and less variability (all p < 0.001). In 2012, 96.1% of patients received opioid prescriptions; the rate fell to 13.5% by 2021. For patients ages, 0-6, the annual rate of opioid prescriptions dropped from a maximum of 96.3% in 2012 to 0.0% in 2021. The annual average supply of doses per prescription decreased by 68% between 2013 and 2021, reducing the total days' supply to an evidence-based 3.1 ± 1.6 days. Regressions did not detect changes in returns to the system. Pain-related returns were rare (0.9%) and did not vary by opioid prescriptions (p = 0.37). Prescribing trends were closely correlated with a tonsillectomy-focused protocol that our institution implemented in 2019.

CONCLUSION

Surgeon-driven opioid stewardship has improved with no resultant change in revisit rates. Procedure-specific quality improvement interventions may have broader off-target effects on prescribing behaviors.

LEVEL OF EVIDENCE

IV Laryngoscope, 2022.

Characterizing opioid prescribing to adolescents at time of discharge from a pediatric hospital over a five-year period

PURPOSE

To characterize opioid prescribing over a 5-year period to adolescents upon discharge from one urban pediatric medical center.

DESIGN AND METHODS

A retrospective cross-sectional analysis of 4354 adolescents discharged with a pain medication after an admission of ≤5 days between January 2015 and December 2019 was performed. Two outcome groups, based on the analgesics prescribed at discharge, were compared: those discharged with a prescription for a non-opioid only and those discharged with an opioid prescription. The association between year of discharge and receipt of opioid, while adjusting for relevant demographic and clinical characteristics, was also explored.

RESULTS

Approximately 64% of the sample was discharged with an opioid prescription. Of those, the median daily dosage was 45.0 morphine milligram equivalents (MME) [IQR: 32.4, 45.0]. Year of discharge was associated with decreased odds of receiving an opioid when adjusting for age, race, sex, insurance, pain scores, opioid exposure during hospitalization, length of stay, and undergoing surgery. The odds of being discharged with an opioid decreased each year by 29% (Adjusted Odds Ratio [AOR] = 0.71, CI:0.68-0.73). Concurrently, the proportion of patients discharged with nonopioid pain medication increased from 25% of adolescent patients in 2015 to 50% in 2019.

CONCLUSIONS

Overall, opioid prescribing to adolescents at time of discharge decreased over time in our sample.

PRACTICE IMPLICATIONS

While prescribing has decreased opioid analgesics are dispensed to young patients. Risk of opioid use disorder and overdose is rare in this population, but adolescence is good opportunity for nursing to promote safe prescribing and analgesic use.

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.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis

INTRODUCTION AND OBJECTIVE

Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events.

STUDY DESIGN

All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated.

RESULTS

438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04).

DISCUSSION

The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries.

CONCLUSIONS

Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

Sustaining standardized opioid prescribing practices after pediatric tonsillectomy

INTRODUCTION

Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes.

METHODS

A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure.

RESULTS

From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28).

CONCLUSION

An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.

Design and implementation of a novel patient-centered empowerment approach for pain optimisation in children undergoing major surgery

Background

Paediatric surgery is a stressful experience for patients and caregivers. While standardised protocols are the norm, patient-centred approaches are needed to empower patients/caregivers for an optimal perioperative pain experience. To address this gap, we employed a patient-centred approach using design thinking (DT) methodology to develop insights, map processes, identify opportunities and design solutions for individualised empowerment tools.

Methods

In consultation with DT experts, a multidisciplinary team of stakeholders (healthcare providers, patients who underwent pectus excavatum/scoliosis surgery and their caregivers), were invited to participate in surveys, interviews and focus groups. The project was conducted in two sequential stages each over 24 weeks—involving 7 families in stage 1 and 16 patients/17 caregivers in stage 2. Each stage consisted of three phases: design research (focus groups with key stakeholders to review and apply collective learnings, map processes, stressors, identify influencing factors and opportunities), concept ideation (benchmarking and co-creation of new solutions) and concept refinement.

Results

In stage 1, mapping of stress/anxiety peaks identified target intervention times. We identified positive and negative influencers as well as the need for consistent messaging from the healthcare team in our design research. Current educational tools were benchmarked, parent-child engagement dyads determined and healthcare-based technology-based solutions conceived. The ‘hero’s journey’ concept which has been applied to other illness paradigms for motivation successfully the was adapted to describe surgery as a transformative experience. In stage 2, patient and caregiver expectations, distinct personas and responses to perioperative experience were categorised. Educational tools and an empowerment tool kit based on sensorial, thinking, relaxation and activity themes, tailored to parent/child categories were conceptualised.

Conclusion

DT methodology provided novel family centred insights, enabling design of tailored empowerment toolkits to optimise perioperative experience. Adapting the hero’s journey call to adventure may motivate and build resilience among children undergoing surgery.

Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice

BACKGROUND

Opioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia.

MATERIAL/METHOD

A systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0-18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records.

RESULTS

Fifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33-100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male - 113, median age - 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04-0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14-0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge.

CONCLUSION

There is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.

Use of Outpatient Opioids Prescribed From a Pediatric Acute Care Setting

OBJECTIVES

Deaths due to prescription opioid overdoses are at record high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy, but little is known about how much is needed to adequately treat acutely painful conditions for outpatients. The purpose of this study was to quantify the usage of opioids prescribed from the pediatric emergency departments of a Midwestern tertiary care children's hospital system.

METHODS

This was a prospective descriptive study in which patients aged 0 to 17 years seen in 2 pediatric emergency departments who received a prescription for an outpatient opioid were enrolled. The main outcome was opioid doses used at home, which was obtained via phone follow-up. Additional information, including patient demographics, location, prescriber specialty, diagnosis, and opioid name and amount prescribed, was obtained via chart review.

RESULTS

A total of 295 patients were enrolled, with 281 completing the study (95%). The median numbers of opioid doses prescribed and used were 12 and 2 doses, respectively, with 9 doses in excess. Patients with lower extremity fractures used more opioids than other diagnoses, with a median of 8 doses. The majority of families reported keeping extra doses at home.

CONCLUSIONS

Prescribed opioid doses exceeded used doses by a factor of 6. Lower extremity fractures required more doses than other acutely painful conditions. We should consider limiting doses prescribed to decrease excess opioids available for misuse and abuse.

Evaluating Providers' Prescription Opioid Instructions to Pediatric Patients

Receiving an opioid prescription during childhood increases the risk of hazardous prescription opioid (PO) use during emerging adulthood. Instruction on how to safely use POs plays an essential role in pediatric patients’ capacity to utilize as well as to discontinue POs appropriately. This study aimed to evaluate pediatric PO label instructions provided to a large sample of pediatric outpatients. Data were extracted from the electronic healthcare records system identifying pediatric patients who received a PO between 2016 and 2019 from pediatric outpatient medical clinics were affiliated with a northwestern United States medical center and children’s hospital. Pediatric patients (n = 12,613) between 0−17 years old who received a PO during outpatient care were included. Patients with chronic health conditions (e.g., cancer) or who received their PO from an inpatient medical setting were excluded. Patient demographics, medication instructions, associated diagnoses, and other prescription information (e.g., name of medication, dose, and quantity dispensed) were examined using automated text classification. Many label instructions did not include any indication/reason for use (20.8%). Virtually none of the POs (>99%) included instructions for how to reduce/wean off POs, contact information for questions about the POs, and/or instructions around how to dispose of the POs. Efforts are needed to ensure that pediatric PO instructions contain essential elements to improve comprehension of when and how to use POs for pediatric patients.

Trends in Routine Opioid Dispensing After Common Pediatric Surgeries in the United States: 2014-2019

Using Joinpoint regression, our study revealed substantial decreases in postoperative opioid dispensing after outpatient pediatric surgeries beginning in 2017.

Multi-Institutional Quality Improvement Project to Minimize Opioid Prescribing in Children after Appendectomy Using NSQIP-Pediatric

BACKGROUND

There is wide variation in opioid prescribing after appendectomy in children and adolescents, with recent increases noted in opioid-related pediatric deaths from prescription and illicit opioids. The goal of this project was to minimize opioid prescribing at the time of discharge for children undergoing appendectomy by using Quality Improvement (QI) methodology.

STUDY DESIGN

Children (18 years of age or less) who underwent appendectomy were evaluated from January to December 2019 using NSQIP-Pediatric at 10 children's hospitals within the Western Pediatric Surgery Research Consortium. Before project initiation, 5 hospitals did not routinely prescribe opioids after appendectomy (protocol). At the remaining 5 hospitals, prescribing was not standardized and varied by surgeon (no-protocol). A prospective multi-institutional QI project was used to minimize outpatient opioid prescriptions for children after appendectomy. The proportion of children at each hospital receiving an opioid prescription at discharge was compared for 6 months before and after the intervention using chi-square analysis.

RESULTS

Overall, 1,524 children who underwent appendectomy were evaluated from January to December 2019. After the QI intervention, overall opioid prescribing decreased from 18.2% to 4.0% (p < 0.001), with significant decreases in protocol hospitals (2.7% vs 0.8%, p = 0.038) and no-protocol hospitals (37.9% vs 8.8%, p < 0.001). The proportion of 30-day emergency room visits did not change after the QI intervention (8.9% vs 9.9%, p = 0.54) and mean postintervention pain management satisfaction scores were high.

CONCLUSION

Opioid prescribing can be minimized in children after appendectomy without increasing emergency room visits or decreasing patient satisfaction. Furthermore, NSQIP-Pediatric can be used as a platform for multi-institutional collaboration for successful implementation of QI projects.

Variability and Excess in Opioid Prescribing Patterns After Cleft and Craniosynostosis Repairs

OBJECTIVE

To critically analyze pediatric opioid prescription patterns after cleft and craniosynostosis repairs.

DESIGN

Observational study 1) retrospectively reviewing pediatric opioid prescriptions from July 2018 to June 2019 and 2) prospectively surveying patients about actual opioid use from August 2019 to February 2020.

SETTING

Academic tertiary care pediatric hospital.

PATIENTS

133 pediatric patients undergoing cleft lip and/or palate or craniosynostosis repairs. Prospective surveys were offered at postoperative visits; 45 of 69 eligible patients were enrolled.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Opioid doses prescribed at discharge and actual home opioid use.

RESULTS

90 patients with cleft lip and/or palate and 43 patients with craniosynostosis were included. Median prescribed opioid doses were 10.3 for cleft lip and/or palate procedures (range 0-75), and 14.3 for craniosynostosis repairs (range 0-50). In patients with cleft lip and/or palate, there was a negative correlation between age at surgery and prescribed opioid doses (r_s  =  -0.228, p  =  0.031). 45 patients completed surveys of home opioid use. No patients used more than 10 doses. Forty percent used no opioids at home, 33% used 1 to 2 doses, 18% used 3 to 5 doses, and 9% used 6 to 10 doses.

CONCLUSIONS

Opioid prescriptions vary widely after common craniofacial procedures. Younger patients with cleft lip and/or palate may be more likely to be prescribed more doses. Actual home opioid use is less than prescribed amounts, with most patients using five or fewer doses. A prescribing guideline is proposed.

Characteristics of Opioid Prescribing in Non-surgical Medicine Patients with Acute Pain at Hospital Discharge

BACKGROUND

The opioid epidemic and new Joint Commission standards around opioid stewardship have made the appropriate prescribing of opioids a priority. A knowledge gap exists pertaining to the short-term prescription of opioids at hospital discharge for acute pain in non-surgical patients.

OBJECTIVE

To characterize the quantity, type, and indication of opioids prescribed for non-surgical patients on hospital discharge and subsequent patient utilization.

DESIGN

This multicenter, single-health system retrospective cohort study was conducted for quality improvement purposes from December 2019 to May 2020 with patient follow-up 15 to 29 days after hospital discharge.

PARTICIPANTS

Patients discharged from a medicine service with new opioid prescriptions, defined as no opioid prescription documented within the past 90 days, were identified as eligible through the electronic health record. Surveys were attempted until a total of 200 were completed, with 374 surveys attempted and a 53% response rate.

INTERVENTION

Patients were contacted via phone and surveyed post-discharge. Surveys consisted of 28 questions and assessed opioid consumption, duration of use, refills, patient satisfaction, and opioid disposal.

MAIN MEASURES

Prescribing indications and morphine milligram equivalents (MME) quantities were collected for patients at discharge. Subsequently, the quantity of prescribed opioids utilized, remaining, and disposed of post-discharge were collected via patient self-reported survey responses.

KEY RESULTS

Indications for opioid prescribing for 200 surveyed patients were grouped into eight broad prescribing categories. A median of 112.5 total MME was prescribed to patients at hospital discharge. Median MME consumed for surveyed patients was 45. The median total MME remaining at time of survey was 35 MME. Only 5.9% of patients who had leftover opioids reported disposal of the medication.

CONCLUSIONS

Given the observed variation in opioid prescribing and utilization data, standardized indication-based opioid prescribing guidance in the non-surgical medical population would help curb the amount of opioids that remain unused post-discharge.

Written Prescription for Over-the-Counter Nonopioid Pain Medications Does Not Increase the Likelihood of Use after Ambulatory Hand and Upper Extremity Surgery

Introduction  This study looked to determine how providing written prescriptions of nonopioids affected postoperative pain medication usage and pain control. Materials and Methods  Patients undergoing hand and upper-extremity surgery ( n = 244) were recruited after the implementation of a postoperative pain control program encouraging nonopioids before opioids. Patients were grouped based on procedure type: bone ( n = 66) or soft tissue ( n = 178). Patients reported postoperative medication consumption and pain control scores. Two-tailed t -tests assuming unequal variance were performed to look for differences in postoperative pain control and medication consumption between those who were and were not given written prescriptions for nonopioids. Results  For both soft tissue and bone procedure patients, a written prescription did not significantly affect patients' postoperative pain control or medication consumption. Regardless of receiving a written prescription, patients who underwent soft tissue procedures consumed significantly more daily nonopioids than opioids. Conclusion  Receiving written prescriptions for nonopioids may not have a significant effect on postoperative pain control or medication consumption. Patients undergoing soft tissue hand and upper extremity procedures may be more likely to consume more daily nonopioids than opioids postoperatively compared to bone procedure patients regardless of whether they receive a written prescription for nonopioids.

Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Leftover Opioid Analgesics and Disposal Following Ambulatory Pediatric Surgeries in the Context of a Restrictive Opioid-Prescribing Policy

BACKGROUND

Opioid analgesics are commonly prescribed for postoperative analgesia following pediatric surgery and often result in leftover opioid analgesics in the home. To reduce the volume of leftover opioids and overall community opioid burden, the State of Tennessee enacted a policy to reduce initial opioid prescribing to a 3-day supply for most acute pain incidents. We aimed to evaluate the extent of leftover opioid analgesics following pediatric ambulatory surgeries in the context of a state-mandated restrictive opioid-prescribing policy. We also aimed to evaluate opioid disposal rates, methods of disposal, and reasons for nondisposal.

METHODS

Study personnel contacted the parents of 300 pediatric patients discharged with an opioid prescription following pediatric ambulatory surgery. Parents completed a retrospective telephone survey regarding opioid use and disposal. Data from the survey were combined with data from the medical record to evaluate proportion of opioid doses prescribed that were left over.

RESULTS

The final analyzable sample of 185 patients (62% response rate) were prescribed a median of 12 opioid doses (interquartile range [IQR], 12-18), consumed 2 opioid doses (IQR, 0-4), and had 10 opioid doses left over (IQR, 7-13). Over 90% (n = 170 of 185) of parents reported they had leftover opioid analgesics, with 83% of prescribed doses left over. A significant proportion (29%, n = 54 of 185) of parents administered no prescribed opioids after surgery. Less than half (42%, n = 71 of 170) of parents disposed of the leftover opioid medication, most commonly by flushing down the toilet, pouring down the sink, or throwing in the garbage. Parents retaining leftover opioids (53%, n = 90 of 170) were most likely to keep them in an unlocked location (68%, n = 61 of 90). Parents described forgetfulness and worry that their child will experience pain in the future as primary reasons for not disposing of the leftover opioid medication.

CONCLUSIONS

Despite Tennessee's policy aimed at reducing leftover opioids, a significant proportion of prescribed opioids were left over following pediatric ambulatory surgeries. A majority of parents did not engage in safe opioid disposal practices. Given the safety risks related to leftover opioids in the home, further interventions to improve disposal rates and tailor opioid prescribing are warranted after pediatric surgery.

Variability in discharge opioid prescribing practices for children: a historical cohort study

PURPOSE

Legitimate opioid prescriptions can increase the risk of misuse, addiction, and overdose of opioids in children and adolescents. This study aimed to describe the prescribing patterns of discharge opioid analgesics following inpatient visits and to determine patient and prescriber characteristics that are associated with prolonged opioid prescription.

METHODS

In a historical cohort study, we identified patients discharged from hospital with an opioid analgesic prescription in a tertiary pediatric hospital from 1 January 2016 to 30 June 2017. The primary outcome was the duration of opioid prescription in number of days. We assessed the association between patient and prescriber characteristics and an opioid prescription duration > five days using a generalized estimating equation to account for clustering due to repeated admissions of the same patient.

RESULTS

During the 18-month study period, 15.4% of all admitted patients (3,787/24,571) were given a total of 3,870 opioid prescriptions at discharge. The median [interquartile range] prescribed duration of outpatient opioid therapy was 3.75 [3.00-5.00] days. Seventy-seven percent of the opioid prescriptions were for five days or less. Generalized estimating equation analysis revealed that hospital stay > four days, oxycodone prescription, and prescription by clinical fellows and the orthopedics service were all independently associated with a discharge opioid prescription of > five days.

CONCLUSIONS

Most discharge opioids for children were prescribed for less than five days, consistent with current guidelines for adults. Nevertheless, the dosage and duration of opioids prescribed at discharge varied widely.

Trends in opioid misuse by cigarette smoking status among US adolescents: Results from National Survey on Drug Use and Health 2015-2018

Increasing rates of opioid-related emergency department visits and deaths among adolescents in the United States are a public health concern. Adolescent cigarette smoking may be a risk factor for opioid misuse; though, there is a paucity of research on adolescents' cigarette smoking and opioid misuse. This study investigates current trends and the association between cigarette smoking and opioid misuse among US adolescents. Using pooled youth samples (ages 12-17) from the National Survey on Drug Use and Health (NSDUH) 2015-2018 (N = 54,866), we calculated weighted estimates of past-year opioid misuse by cigarette smoking status across years. We further estimated a multivariable logistic regression model to examine the past-year opioid misuse by ever-cigarette-smoking, controlling for sociodemographics and other substance use. While there was a significant reduction in opioid misuse among the entire sample and among never-smokers over time (2.5% in 2015 to 1.9% in 2018), this trend was not significant among ever-smokers (14.2% in 2015 to 11.1% in 2018). Multivariable logistic regression showed ever-smokers (vs. never-smokers) had higher odds of past-year opioid misuse (aOR = 2.01; 95% CI = 1.66, 2.43). Findings suggest that comprehensive tobacco control policies and opioid misuse prevention programs are warranted to curb opioid misuse among adolescents.

Improving Opioid Stewardship in Pediatric Emergency Medicine

OBJECTIVES

Poor opioid stewardship contributes to opioid misuse and adverse health outcomes. We sought to decrease opioid prescriptions in children 0 to 18 years treated for pain after fractures and cutaneous abscess drainage from 13.5% to 8%. Our secondary aims were to reduce opioid prescriptions written for >3 days from 41% to 10%, eliminate codeine prescriptions, increase safe opioid storage and disposal discharge instructions from 0% to 70%, and enroll all emergency department (ED) physicians in the state prescription drug monitoring program.

METHODS

We implemented an intervention bundle on the basis of 4 key drivers at a pediatric ED: ED-wide education, changes in the electronic medical record, discharge resources, and process standardization. Two plan-do-study-act cycles were performed. Interventions included provider feedback on prescribing, safe opioid storage and disposal instructions, and streamlined electronic medical record functions. Run charts were used to analyze the effect of interventions on outcomes. Our balance measure was return ED or clinic visits for inadequate analgesia within 3 days.

RESULTS

During the intervention period, 249 of 3402 (7.3%) patients with fractures and cutaneous abscesses were prescribed opioids. The percentage of opioid prescriptions >3 days decreased from 41% to 13.2% (P < .0001), codeine prescription dropped from 1.1% to 0% (P = .09), opioid discharge instructions increased 0% to 100% (P < .0001), and all physicians enrolled in the prescription drug monitoring program. There was no change in return visits for uncontrolled analgesia compared with the baseline (P = .79).

CONCLUSIONS

A comprehensive opioid stewardship program can improve opioid prescribing practices of ED physicians and deliver information on safe storage and disposal of prescription opioids with a negligible effect on return visits for uncontrolled pain.

Reducing Children's Preoperative Fear with an Educational Pop-up Book: A Randomized Controlled Trial

OBJECTIVE

Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies.

STUDY DESIGN

Prospective randomized controlled trial.

SETTING

Pediatric outpatient surgery center.

METHODS

Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction.

RESULTS

In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients' fear of anesthesia induction (Cohen's d effect size = 0.94; P < .001). Intervention patients also expected less pain than control patients from the anesthesia mask and during surgery (d = 0.60-0.80; P < .001). The book encouraged more positive views of the procedure and preoperative explanations (P < .005). Furthermore, the book prepared patients to cope adaptively: intervention patients were significantly more likely to generate positive active coping strategies, distraction strategies, and support-seeking strategies (P < .001). Observer-rated behavioral anxiety at anesthesia induction did not differ between groups (P = .75). Caregivers in the intervention group were significantly more satisfied with each aspect of the surgical experience (P≤ .02).

CONCLUSION

The educational pop-up book offers a child-focused resource that helps alleviate children's preoperative fears, encourages positive coping, and improves caregivers' perceptions of the experience. This study was registered at ClinicalTrials.gov (NCT04796077).

Trends and risk factors for opioid administration for non-emergent lower back pain

BACKGROUND

Non-emergent low-back pain (LBP) is one of the most prevalent presenting complaints to the emergency department (ED) and has been shown to contribute to overcrowding in the ED as well as diverting attention away from more serious complaints. There has been an increasing focus in current literature regarding ED admission and opioid prescriptions for general complaints of pain, however, there is limited data concerning the trends over the last decade in ED admissions for non-emergent LBP as well as any subsequent opioid prescriptions by the ED for this complaint.

AIM

To determine trends in non-emergent ED visits for back pain; annual trends in opioid administration for patients presenting to the ED for back pain; and factors associated with receiving an opioid-based medication for non-emergent LBP in the ED

METHODS

Patients presenting to the ED for non-emergent LBP from 2010 to 2017 were retrospectively identified from the National Hospital Ambulatory Medical Care Survey database. The “year” variable was transformed to two-year intervals, and a weighted survey analysis was conducted utilizing the weighted variables to generate incidence estimates. Bivariate statistics were used to assess differences in count data, and logistic regression was performed to identify factors associated with patients being discharged from the ED with narcotics. Statistical significance was set to a P value of 0.05.

RESULTS

Out of a total of 41658475 total ED visits, 3.8% (7726) met our inclusion and exclusion criteria. There was a decrease in the rates of non-emergent back pain to the ED from 4.05% of all cases during 2010 and 2011 to 3.56% during 2016 and 2017. The most common opioids prescribed over the period included hydrocodone-based medications (49.1%) and tramadol-based medications (16.9), with the combination of all other opioid types contributing to 35.7% of total opioids prescribed. Factors significantly associated with being prescribed narcotics included age over 43.84-years-old, higher income, private insurance, the obtainment of radiographic imaging in the ED, and region of the United States (all, P < 0.05). Emergency departments located in the Midwest [odds ratio (OR): 2.42, P < 0.001], South (OR: 2.35, < 0.001), and West (OR: 2.57, P < 0.001) were more likely to prescribe opioid-based medications for non-emergent LBP compared to EDs in the Northeast.

CONCLUSION

From 2010 to 2017, there was a significant decrease in the number of non-emergent LBP ED visits, as well as a decrease in opioids prescribed at these visits. These findings may be attributed to the increased focus and regulatory guidelines on opioid prescription practices at both the federal and state levels. Since non-emergent LBP is still a highly common ED presentation, conclusions drawn from opioid prescription practices within this cohort is necessary for limiting unnecessary ED opioid prescriptions.

Opioid Prescribing to US Children and Young Adults in 2019

BACKGROUND

Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years.

METHODS

We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with ≥1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by ≥1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the ≥95th percentile.

RESULTS

Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had ≥1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of ≥50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by ≥1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions.

CONCLUSIONS

Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.

Pediatric Urologic Surgery: Reducing Opioid Use

Adequate pain management is important for successful postoperative recovery after any surgical procedure. Unfortunately, the USA and many other parts of the world are in the midst of an opioid epidemic, and healthcare providers are thus tasked with balancing the comfort and recovery of their patients after an operation against the individual and societal harms of the over-prescription of opioids. The goal of this article is to discuss the range of opioid formulations currently in use, examine why this may be problematic, and explore alternatives that provide similar efficacy and may improve overall safety in the pediatric population after urologic surgery. Improving the way opioids are prescribed through clinical practice guidelines as well as considering alternatives to opioids can ensure patients have access to safer and more effective pain treatments and potentially reduce opioid misuse.

Patient-reported opioid analgesic use after discharge from surgical procedures: a systematic review

OBJECTIVE

This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use post-surgery.

METHODS

We searched Pubmed (February 2019), Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized use, and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale.

RESULTS

Ninety-six studies met eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5 mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as < 5 tablets. In studies that examined excess tablets, 25%-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50%-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies due to heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria.

CONCLUSION

Self-reported post-surgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.

Impact of a revised postoperative care plan on pain and recovery trajectory following pediatric tonsillectomy

BACKGROUND

A previous cohort of adenotonsillectomy patients at our institution demonstrated moderate-severe post-tonsillectomy pain scores lasting a median (range) duration of 6 (0-23) days and postdischarge nausea and vomiting affecting 8% of children on day 1 following surgery. In this subsequent cohort, we evaluate the impact of changes to our discharge medication and parental education on post-tonsillectomy pain and recovery profile.

METHODS

In this follow-on, prospective observational cohort study, all patients undergoing tonsillectomy at our institution during the study period were discharged with standardized analgesia. Parents received a revised education package and a medication diary which were not provided to the previous cohort. Pain scores, rates of nausea and vomiting, medication usage and unplanned representation rates were collected by telephone from parents.

RESULTS

Sixty-nine patients were recruited. Moderate-severe pain lasted a median (range) of 5 (0-12) days. Twenty-nine (42%) had pain scores ≥4/10 beyond postoperative day 7. By postoperative day 5, only 37 (53%) parents continued to administer regular analgesia. The median number of oxycodone doses used was 5 (0-22), and only 28 (41%) parents had disposed of leftover oxycodone within 1 month of surgery. Twenty-four (35%) patients experienced nausea or vomiting postdischarge. The median (range) time for return to normal activities was 6 (0-14) days. Thirty-two/sixty-nine (46%) patients had unplanned medical representations. Most occurred between postoperative day 5 and 7. Pain contributed to 16 (35%) representations.

CONCLUSIONS

Despite extensive changes to our discharge protocols parents continued to report a prolonged period of pain, post operative nausea and vomiting, and behavioral changes. Further work is required to examine barriers to compliance with simple analgesia and education in appropriate methods of opioid disposal.

Effect of Drug Disposal Kits and Fact Sheets on Elimination of Leftover Prescription Opioids: The DISPOSE Multi-Arm Randomized Controlled Trial

OBJECTIVE

To determine how passively providing informational handouts and/or drug disposal kits affects rates of leftover prescription opioid disposal.

DESIGN

A multi-arm parallel-group randomized controlled trial with masked outcome assessment and computer-guided randomization.

SETTING

Johns Hopkins Health System outpatient pharmacies.

SUBJECTS

Individuals who filled ≥1 short-term prescription for an immediate-release opioid for themselves or a family member.

METHODS

In June 2019, 499 individuals were randomized to receive an informational handout detailing U.S. Food and Drug Administration-recommended ways to properly dispose of leftover opioids (n = 188), the informational handout and a drug disposal kit with instructions on its use (n = 170), or no intervention (n = 141) at prescription pickup. Subjects were subsequently contacted by telephone, and outcomes were assessed by a standardized survey. The primary outcome was the use of a safe opioid disposal method.

RESULTS

By 6 weeks after prescription pickup, 227 eligible individuals reported they had stopped taking prescription opioids to treat pain and had leftover medication. No difference in safe disposal was observed between the non-intervention group (10% [6/63]) and the group that received disposal kits (14% [10/73]) (risk ratio = 1.44; 95% confidence interval: 0.55 to 3.74) or the group that received a fact sheet (11% [10/91]) (risk ratio = 1.15; 95% confidence interval: 0.44 to 3.01).

CONCLUSIONS

These findings suggest that passive provision of a drug disposal kit at prescription pickup did not increase rates of leftover opioid disposal when compared with provision of a fact sheet alone or no intervention. Active interventions may deserve further investigation.

Association between Paravertebral Block and Pain Score at the Time of Hospital Discharge in Oncoplastic Breast Surgery: A Retrospective Cohort Study

BACKGROUND

Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge.

METHODS

The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression.

RESULTS

Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001).

CONCLUSION

Paravertebral blocks are associated with decreased pain score at the time of hospital discharge.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.