Physicians Prescribe More Opioid Than Needed to Treat Pain in Children After Outpatient Urological Procedures: An Observational Cohort Study

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.

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.

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.

Opioid prescription usage and disposal after provider education and SMS-based parent education

INTRODUCTION

Adequate pain control after outpatient pediatric urologic surgery is important for both providers and caregivers; however, opioid pain medications are often prescribed in excess of utilization. The resultant excess opioid medication has potential to be diverted or misused. While families are instructed to dispose of leftover opioids, a significant proportion may not dispose of leftover medication. We performed a quality improvement (QI) initiative within a tertiary academic care center to examine opioid excess, opioid disposal, and whether a two-component QI intervention of provider education and family education via automated SMS messages on opioid disposal could improve excess opioid prescribing and leftover opioid disposal.

MATERIALS AND METHODS

Prospective parent surveys were performed on a baseline cohort of 73 patients undergoing outpatient pediatric urologic surgery between July 27 and September 4, 2020. Based on baseline data, a two-component quality improvement initiative was implemented. The first component was non-binding surgeon education regarding opioid prescribing versus opioid utilization. The second component was initiation of automated SMS messages to families after surgery with information on expected postoperative course and hyperlinked instructions for opioid disposal with GPS search for opioid disposal sites nearby. We then repeated the survey for a second cohort of patients between September 14 and October 29, 2021, including additional questions regarding SMS message utility.

RESULTS

Of 73 patients in the baseline group, 46% were prescribed opioids (Summary Table). Of patients prescribed opioids, a median of 3 doses were used and 96% had leftover opioid medication. Seventeen percent of parents in the baseline group disposed of unused opioids prior to survey completion (1-4 weeks postop). After the intervention, 19 of 74 (26%) patients were prescribed opioids. In the group that received opioids, a median of 2 doses were used and 63% reported disposing of opioids. Ninety-six percent of parents reported satisfaction with SMS messages.

DISCUSSION

Many competing priorities exist for surgical providers and parents of children undergoing outpatient pediatric urologic surgery. A passive program that delivers just-in-time information in the postoperative period has high utility for both parents and providers.

CONCLUSIONS

Automated SMS messages and provider education about opioid utilization are associated with decreased excess opioid after outpatient pediatric urologic surgery and improved opioid disposal rates by parents. These interventions are easily implemented without significant manpower and should be considered by organizations interested in decreasing excess community opioids after outpatient pediatric urologic surgery.

Elimination of postoperative narcotics in infant robotic pyeloplasty using caudal anesthesia and a non-narcotic pain pathway

INTRODUCTION

Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for post-operative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics following infant robotic pyeloplasty.

METHODS

We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes and unscheduled healthcare encounters within 30 postoperative days.

RESULTS

63% (15/24) patients were male and average age was 12.1 months (range 4-34 months). 58% (9/15) underwent surgery on the left. 16.7% (4/24) of patients received a single postoperative dose of narcotics in the PACU. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related, unscheduled visits or phone calls after discharge.

CONCLUSIONS

This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Post procedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.

Ambulatory Pain Management in the Pediatric Patient Population

PURPOSE OF REVIEW

Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

RECENT FINDINGS

A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

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.

The impact of patient age and procedure type on postoperative opioid use following ambulatory pediatric urologic procedures

PURPOSE

The aim of this study is to determine whether patient age and procedure type are associated with duration of opioid use in pediatric patients undergoing ambulatory urologic procedures.

METHODS

We retrospectively reviewed pediatric patients who underwent outpatient urologic procedures from 2013 to 2017. At postoperative visits, parents reported the number of days their child took opioid pain medication. Factors associated with duration of opioid use were evaluated using negative binomial regression models.

RESULTS

805 patients were included: 320 infants (39.8%), 430 children (53.4%), and 55 adolescents (6.8%). Overall mean length of opioid use was 1.7 (± 2.6) days. On average, infants used opioids for the shortest duration: 1.5 (± 2.3) days, followed by children: 1.7 (± 2.5) days, and adolescents: 3.1 (± 4.6) days. In adjusted models, adolescents used opioids for 85.2% longer (95% CI 13.1-161.8%; p < 0.001) than children and infants used opioids for 19.4% shorter duration (95% CI 0.4-34.7%; p = 0.05) than children. Each 1-year increase in age was associated with 6.1% increased duration of opioid use (95% CI 3.9-8.5%; p < 0.0001). Patients who underwent circumcision, hypospadias repair, and penile reconstruction took opioids for 75.9% (95% CI 42.6-117.1%; p < 0.001), 144.2% (95% CI 76.4-238.0%; p < 0.001), and 126.7% (95% CI 48.8-245.3%; p < 0.001) longer respectively than patients who underwent inguinal procedures.

CONCLUSIONS

Increasing age, circumcision, hypospadias repair, and penile reconstruction are associated with increased duration of opioid use.

Postoperative Disposal of Unused Opioids: A Systematic Review

Introduction: Opioid misuse and overprescription have contributed to a national public health crisis in the United States. Postoperatively, patients are often left with unused opioids, which pose a risk for diversion if not appropriately disposed of. Patients are infrequently provided instructions on safe disposal methods of surplus opioids. Purpose: We sought to determine the current rates of disposal of unused opioids and the reported disposal mechanisms for unused opioids that were prescribed for acute postoperative pain control. Methods: A systematic review was performed of the PubMed, Cochrane, and Embase databases for relevant articles from their earliest entries through October 2, 2019. We used the search terms "opioid" or "narcotic" and "disposal" and "surgery." Studies were considered for inclusion if they reported the rate of disposal of unused opioids following surgery. A screening strategy was used to identify relevant articles using Covidence. For studies meeting inclusion criteria, relevant information was extracted. Results: Sixteen studies met inclusion criteria. We found that surplus opioid disposal rates varied widely, from 4.9% to 87.0%. Among studies with no intervention (opioid disposal education or drug disposal kit/bag), rates of opioid disposal ranged from 4.9% to 46.5%. While 7 studies used opioid disposal education as an intervention, only 3 showed a significant increase in surplus opioid disposal compared with standard care. All 3 studies that used an opioid disposal kit or bag as an intervention demonstrated significant increases in opioid disposal. Conclusions: Baseline rates of surplus opioid disposal are relatively low in the postoperative setting. Our findings suggest that opioid disposal kits significantly increase rates of surplus opioid disposal postoperatively. Further research, including a large-scale cost-benefit analysis, will be necessary prior to recommending widespread implementation of drug disposal kits or bags.

Pediatric surgeon opioid prescribing behavior: A survey of the American Pediatric Surgery Association membership

BACKGROUND

The opioid crisis has led to increasing numbers of overdose fatalities in teens and young adults. Surgery, as a common cause of acute pain in children, drives much of the opioid prescribing in pediatrics. Therefore, we sought to characterize opioid prescribing practices of pediatric surgeons by surveying members of the American Pediatric Surgery Association (APSA).

STUDY DESIGN

After receiving approval from our institutional review board, we sent an online survey to the entire APSA membership. The survey included four vignettes of common pediatric surgical procedures with questions regarding analgesic prescribing practices, the rationale for these practices, and knowledge about opioid risk mitigation.

RESULTS

Of 1127 APSA members contacted, 327 (29%) provided survey responses. For all vignettes, opioid prescribing was within standard ranges for 83% of respondents. Eighty-eight percent of respondents prescribed nonopioid pain medicine. Additionally, 25% reported routinely utilizing a prescription drug monitoring program, 64% did not tell patients how to dispose of opioids, and 37% did not know themselves how to dispose of leftover opioids.

CONCLUSIONS

Prescribing by APSA surgeons is largely within standard ranges, but improvement is needed, particularly regarding opioid disposal. Procedure-specific consensus guidelines for opioid prescribing and opioid risk mitigation strategies are warranted.

LEVEL OF EVIDENCE

Observational study, level III.

Opioid prescribing to preteen children undergoing ambulatory surgery in the United States

BACKGROUND

Overuse and misuse of opioids is a continuing crisis. The most common reason for children to receive opioids is postoperative pain, and they are often prescribed more than needed. The amount of opioids prescribed varies widely, even for minor ambulatory procedures. This study uses a large national sample to describe filled opioid prescriptions to preteen patients after all ambulatory surgical procedures and common standard procedures.

METHODS

We analyzed Truven Health MarketScan data for July 2012 through December 2016 to perform descriptive analyses of opioid fills by age and geographic area, change over time, second opioid fills in opioid-naïve patients, and variation in the types and amount of medication prescribed for 18 common and standard procedures in otolaryngology, urology, general surgery, ophthalmology, and orthopedics.

RESULTS

Over 10% of preteen children filled perioperative opioid prescriptions for ambulatory surgery in the period 2012 to 2016. The amount prescribed varied widely (median 5 days' supply, IQR 3-8, range 1-90), even for the most minor procedures, for example, frenotomy (median 4 days' supply, IQR 2-5, range 1-60). Codeine fills were common despite safety concerns. Second opioid prescriptions were filled by opioid-naïve patients after almost all procedures studied. The rate of prescribing declined significantly over time and varied substantially by age and across census regions.

CONCLUSIONS

We identified opioid prescribing outside of the norms of standard practice in all of the specialties studied. Standardizing perioperative opioid prescribing and developing guidelines on appropriate prescribing for children may reduce the opioids available for misuse and diversion.

Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery

BACKGROUND

Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain.

OBJECTIVES

As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures.

METHODS

We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure).

RESULTS

Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p < 0.01). There was significant variation in opioid prescribing patterns by provider (p < 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries.

CONCLUSIONS

Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.

Validating an opioid prescribing algorithm in post-operative pediatric surgical oncology patients

PURPOSE

We developed an algorithm to decrease opioid prescriptions for pediatric oncology patients at discharge following surgery, based on a retrospective analysis to decrease variability and over-prescribing. The aim of this study was to prospectively test the algorithm.

METHODS

Opioid-naïve patients undergoing surgery for tumor resection at a single institution were included. A prescribing algorithm was developed based on surgical approach, day of discharge, and inpatient opioid use. Prospectively collected data included outpatient opioid consumption and patient/family satisfaction. Total home dose prescribed was equal to that used in the 8 or 24 h, depending on length of stay and operative approach, prior to discharge, divided into 0.15 mg/kg doses.

RESULTS

The algorithm was used in 121 patients and correctly predicted outpatient opioid requirements for 102 patients (84.3%). For 15 (12.4%) patients, the algorithm over-estimated opioid need by an average of 0.38 OME/kg. Four (3.3%) patients required additional opioids. Using this algorithm, we decreased overall opioid prescriptions from 6.17 to 0.21 OME/kg (p < 0.001), and all but one patient/family reported being satisfied with post-operative pain control.

CONCLUSION

Using an algorithm based on inpatient opioid use, outpatient opioid needs can be accurately predicted, thereby reducing excess opioid prescriptions without detriment to patient satisfaction.

TYPE OF STUDY

Prospective Quality Initiative Study.

LEVEL OF EVIDENCE

Level III.

Incidence of and Factors Associated With Prolonged and Persistent Postoperative Opioid Use in Children 0-18 Years of Age

BACKGROUND

Long-term opioid use has negative health care consequences. Opioid-naïve adults are at risk for prolonged and persistent opioid use after surgery. While these outcomes have been examined in some adolescent and teenage populations, little is known about the risk of prolonged and persistent postoperative opioid use after common surgeries compared to children who do not undergo surgery and factors associated with these issues among pediatric surgical patients of all ages.

METHODS

Using a national administrative claims database, we identified 175,878 surgical visits by opioid-naïve children aged ≤18 years who underwent ≥1 of the 20 most common surgeries from each of 4 age groups between December 31, 2002, and December 30, 2017, and who filled a perioperative opioid prescription 30 days before to 14 days after surgery. Prolonged opioid use after surgery (filling ≥1 opioid prescription 90-180 days after surgery) was compared to a reference sample of 1,354,909 nonsurgical patients randomly assigned a false "surgery" date. Multivariable logistic regression models were used to estimate the association of surgical procedures and 22 other variables of interest with prolonged opioid use and persistent postoperative opioid use (filling ≥60 days' supply of opioids 90-365 days after surgery) for each age group.

RESULTS

Prolonged opioid use after surgery occurred in 0.77%, 0.76%, 1.00%, and 3.80% of surgical patients ages 0-<2, 2-<6, 6-<12, and 12-18, respectively. It was significantly more common in surgical patients than in nonsurgical patients (ages 0-<2: odds ratio [OR] = 4.6 [95% confidence interval (CI), 3.7-5.6]; ages 2-<6: OR = 2.5 [95% CI, 2.1-2.8]; ages 6-<12: OR = 2.1 [95% CI, 1.9-2.4]; and ages 12-18: OR = 1.8 [95% CI, 1.7-1.9]). In the multivariable models for ages 0-<12 years, few surgical procedures and none of the other variables of interest were associated with prolonged opioid use. In the models for ages 12-18 years, 10 surgical procedures and 5 other variables of interest were associated with prolonged opioid use. Persistent postoperative opioid use occurred in <0.1% of patients in all age groups.

CONCLUSIONS

Some patient characteristics and surgeries are positively and negatively associated with prolonged opioid use in opioid-naïve children of all ages, but persistent opioid use is rare. Specific pediatric subpopulations (eg, older patients with a history of mood/personality disorder or chronic pain) may be at markedly higher risk.