Opioid Prescription and Usage in Adolescents Undergoing Orthopaedic Surgery in the United States: A Systematic Review

Postoperative Opioid Usage and Disposal Strategies After Arthroscopic Procedures in a Young Cohort: A Prospective Observational Study

Background

Although several studies have noted that patients are routinely overprescribed opioids, few have reported usage after arthroscopic surgery.

Purpose

To determine opioid consumption and allocation for unused opioids after common arthroscopic surgeries.

Study Design

Case series; Level of evidence, 4.

Methods

Patients between the ages of 15 and 40 years who were scheduled to undergo anterior cruciate ligament reconstruction (ACLR), labral repair of the hip or shoulder, meniscectomy, or meniscal repair were prospectively enrolled. Patients were prescribed either 5 mg hydrocodone-325 mg acetaminophen or 5 mg oxycodone-325 mg acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milligram equivalents (MMEs).

Results

Of the 200 patients who were enrolled in the study, 176 patients had sufficient follow-up after undergoing 85 (48%) ACLR, 26 (14.8%) hip labral repair, 34 (19.3%) shoulder labral repair, 18 (10.2%) meniscectomy, and 13 (7.4%) meniscal repair procedures. Mean age was 26.1 years (SD, 7.38); surgeons prescribed a mean of 26.6 pills whereas patients reported consuming a mean of 15.5 pills. The mean MME consumption in the 14 days after each procedure was calculated: ACLR (95.7; 44% of prescription), hip labral repair (84.8; 37%), shoulder labral repair (57.2; 35%), meniscectomy (18.4; 27%), and meniscal repair (32.1; 42%). This corresponded to approximately 39% of the total opioid prescription being utilized across all procedures. Mean MME consumption was greatest on postoperative day 1 in hip, shoulder, and meniscal procedures and on postoperative day 2 in ACLR. Only 7.04% of patients reported continued opioid use in the third postoperative week. Patients had a mean of 11 unused pills or 77.7 MMEs remaining. Of the patients with remaining medication, 24.7% intended to keep their medication for future use.

Conclusion

The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume <75 MMEs in the 2-week postoperative period, translating into a mean of 10 to 15 pills consumed. Approximately 60% of total opioids prescribed went unused, and one-fourth of patients intended to keep their remaining medication for future usage. We have provided general prescribing guidelines and recommend that surgeons carefully consider customizing their opioid prescriptions on the basis of procedure site to balance optimal postoperative analgesia with avoidance of dissemination of excess opioids.

Opioids and Youth Athletes

CONTEXT

The ongoing opioid epidemic and associated adverse effects impart a large burden on our current healthcare system. The annual economic and noneconomic cost of opioid use disorder and fatal opioid overdose is currently estimated at $1 trillion.

OBJECTIVE

This review presents the prevalence, frequency of use, need, and effectiveness of opioid analgesia in the youth and adolescent athlete population. It identifies current indications for opioid versus nonopioid analgesic use in the setting of acute orthopaedic injuries, postoperative management, concussion, and chronic pain. Current knowledge of youth athlete opioid use, risks related to use, misuse, diversion, and addiction are reviewed.

DATA SOURCES

A PubMed, Medline, and Cochrane Library search was conducted in February 2023 to review opioid pain management strategies in the pediatric athlete population from 2000 to present.

STUDY SELECTION

Searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by all authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies.

STUDY DESIGN

Narrative review.

LEVEL OF EVIDENCE

Level 3.

DATA EXTRACTION

First author name, publication year, study design, study country, subject demographics, and data on the frequency, type, and duration of analgesic treatments for musculoskeletal injuries, postsurgical care, chronic pain disorders, and concussion were extracted.

RESULTS

Pediatric athletes comprise a high-risk population seeking analgesic relief for injury-related pain. Participation in high school sports is associated with increased risk of opioid use. An average of 28% to 46% of high school athletes have used opioids in their lifetime. Participation in ≥1 high school sport puts adolescents at 30% greater odds of future opioid misuse.

CONCLUSION

The use of opioids in the pediatric athlete population is common and associated with both short- and long-term risks of misuse and addiction.

Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents

The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].

Application of surface-layer matrix-assisted laser desorption/ionization mass spectrometry imaging to pharmaceutical-loaded poly(ester urea) films

Polymer thin films are often used in transdermal patches as a method of continuous drug administration for patients with chronic illness. Understanding the drug segregation and distribution within these films is important for monitoring proper drug release over time. Surface-layer matrix-assisted laser desorption/ionization mass spectrometry imaging (SL-MALDI-MSI) is a unique analytical technique that provides an optical representation of chemical compositions that exist at the surface of polymeric materials. Solvent-free sublimation is employed for application of matrix to the sample surface, so that only molecules in direct contact with the matrix layer are detected. Here, these methodologies are utilized to visualize variations in drug concentration at both the air and substrate interface in pharmaceutical-loaded polymer films.

Opioid Use After Knee Arthroscopy in Adolescent Patients: A Prospective Evaluation

Background

There is a relative paucity of literature on how to best treat postoperative pain after knee arthroscopy in the adolescent population.

Purpose

To evaluate the use of opioid medication after knee arthroscopy in adolescent patients.

Study Design

Case series; Level of evidence, 4.

Methods

We prospectively enrolled 50 patients aged 10 to 18 years who underwent 1 of the following procedures: diagnostic arthroscopy; plica excision; loose body removal; debridement; chondroplasty; meniscal repair; and/or partial meniscectomy. Patients already taking chronic pain medication and those undergoing revision knee arthroscopy, ligamentous reconstruction, or bony osteotomy procedures were excluded. Postoperatively, the patients were prescribed 15 tablets of hydrocodone/acetaminophen (5 mg/325 mg) every 6 hours as needed for pain. The patients were given a diary to record the number of postoperative opioid pills taken, days the pills were taken, pain level, and nonopioid pills taken. The data were collected and used to identify the mean number of opioid pills needed as well as the number of days opioid medication was needed postoperatively.

Results

Of the 50 enrolled patients, 35 patients adequately completed the diary and were included in the study. The mean age in this cohort was 14.2 years. The total number of pills taken ranged from 0 to 14, with an overall mean of 5.41. Therefore, on average, patients utilized 36% of their postoperative prescriptions. In our cohort, 74.3% of patients had stopped taking opioids by postoperative day 3, with a mean of 3.8 pills, and 97.1% of patients had stopped taking opioids by postoperative day, 5 with a mean of 5.3 pills. No postoperative refills of opioid medication were necessary.

Conclusion

After knee arthroscopy, the adolescents in our study consumed a mean of 5.41 opioid pills postoperatively, and over 97% of patients stopped opioid use by postoperative day 5. The results of this study should help in guiding physicians to avoid overprescribing opioid medication while treating postoperative pain after knee arthroscopy in this vulnerable patient population.

Opioid Represcriptions After ACL Reconstruction in Adolescents Are Associated With Subsequent Opioid Use Disorder

INTRODUCTION

Postoperative opioid prescriptions may confer a risk for subsequent opioid use disorders (OUDs). For many children, postoperative analgesia is often the first opioid exposure. The rates of anterior cruciate ligament (ACL) reconstruction in pediatric populations are rising. Here, we use an administrative claims database to describe opioid prescription patterns after ACL reconstruction and their effect on subsequent risk of OUD.

METHODS

Using International Classification of Diseases (ICD)-9, ICD-10, and CPT codes, we identified patients, with ages 10 to 18, undergoing primary ACL reconstruction between 2014 and 2016 with minimum 1 year follow-up in the Optum Clinformatics Data Mart, which is a nationally representative administrative claims database. Demographic variables and prescription patterns (in morphine milligram equivalents [MMEs]) were analyzed using univariate tests and multivariable logistic regression to determine any potential association with the appearance of anew an ICD-9 or ICD-10 code for OUD within 1 year of the initial procedure.

RESULTS

A total of 4459 cases were included and 29 (0.7%) of these patients were diagnosed with an OUD within 1 year of surgery. Upon univariate analysis, opioid represcriptions within 6 weeks were significantly more common among patients with OUD; 27.6% vs. 9.7% of patients that did not develop a new diagnosis of OUD ( P =0.005). Multivariable logistic regression indicated an independent significant relationship between total MMEs initially prescribed and the odds of a subsequent OUD diagnosis: for each additional 100 MMEs prescribed in total, the odds of OUD increased by 13% ( P =0.002). Patients with a represcription within 6 weeks of surgery had an average increase in the odds of OUD by 161% ( P =0.027).

CONCLUSIONS

In this cohort of patient ages 10 to 18 undergoing primary isolated ACL reconstruction, we found substantial variability in opiate prescribing patterns and higher initial opioid prescription volume, as well as opioid represcription within 6 weeks were predictive of the subsequent development of OUD.

LEVEL OF EVIDENCE

Level III.

Do Continuous Peripheral Nerve Blocks Decrease Home Opioid Use Following Anterior Cruciate Ligament Reconstruction in Children and Adolescents? The Envelope Please

BACKGROUND

Levels of opioid misuse and addiction among children and adolescents have reached alarming proportions. Exposure to opioids after surgery for anterior cruciate ligament reconstruction (ACLR), which is commonly performed in young athletes, increases this risk. This study was designed to evaluate whether continuous peripheral nerve block (CPNB) with placement of an elastomeric reservoir ball, compared with single-shot peripheral nerve block (SPNB), would decrease the need for home opioid analgesia and improve pain control after ACLR in children and adolescents.

METHODS

Prospectively collected data from a consecutive cohort that underwent ACLR by a single surgeon were retrospectively reviewed. Patients who received ACLR with 72-hour CPNB were assigned to Group 1. Patients who received ACLR with SPNB were assigned to Group 2. Postoperative pain management included cryotherapy, oral acetaminophen, and ibuprofen. A prescription for 10 doses of hydrocodone/acetaminophen (5/325 mg) was provided in a sealed envelope with instructions that the prescription should only be used in the case of uncontrolled pain. Reports of no opioid use were corroborated by the unopened envelope and unfilled prescription.

RESULTS

One hundred and ninety-six patients were enrolled in the study (SPNB=114 patients, CPNB=82 patients). Average age was 15±1.5 years (115 female). A total of 138 patients (70%) did not need home opioid analgesia after surgery. Of the 58 patients (30%) that did there were 35 (30.7%) in the SPNB group and 23 (28.0%) in the CPNB group (P=0.659). There were no differences between groups in demographics, operative data, or visual analog scale scores on any postoperative day.

CONCLUSION

The findings of this study demonstrate equivalent pain control and opioid consumption in children and adolescents undergoing ACLR treated with either a CPNB or a SPNB. At-home opioid analgesia use can be negated after ACLR in 70% of children and adolescents. For the patients in this study who required opioids, average use was only 2 pills of 5 mg hydrocodone/325 mg acetaminophen, with no child using more than 10 pills.

LEVEL OF EVIDENCE

Level II-therapeutic.

How Much Opioid Do Kids Actually Need? A Prospective Study of Analgesic Prescribing and Postdischarge Opioid Use Among Pediatric Patients With Operative Fractures

BACKGROUND

Analgesic guidelines are lacking for most operative pediatric fractures, and little is known about postdischarge opioid use or pain control. We hypothesized that opioid/acetaminophen/non-steroidal anti-inflammatory drugs (NSAID) prescribing would vary, pain would be well controlled, and postdischarge opioid use would be low.

METHODS

This prospective cohort study included nonpolytraumatized patients aged 17 years and below with operative fractures at a level 1 trauma center from August 1, 2019 to March 31, 2021. Supracondylar humerus fractures were excluded since they have been studied extensively. Information regarding injury/surgery/analgesics were collected. Discharged patients were called on postoperative days (POD) 1/3/5. Parents/guardians were asked about analgesic use and pain over the preceding 2 days. Complications, pain control, and opioid refills were recorded after first follow-up.

RESULTS

All 100 eligible patients were included. Mean age was 10.1 years (range: 1.8 to 17.8 y). Common fracture types were humeral condyle/epicondyle (28%), radius/ulna (15%), and femoral shaft (13%). Opioids were prescribed to 95% of patients with mean 14 doses (range: 2 to 45). Acetaminophen/NSAIDs were prescribed to 74% and 60% of patients, respectively. Eleven patients were excluded from telephone follow-up (7 non-English speaking, 3 prohibitive social situations, 1 inpatient POD1 to 5). Telephone follow-up was completed for 87/89 eligible patients (98%). Mean pain scores declined from 3.7/10 POD1 to 2.4/10 POD5. Opioids were taken by 50% POD1, 20% POD5. Acetaminophen/NSAID was given before opioid 82% of the time. By POD5, mean total doses of opioid taken postdischarge was 2.3; mean proportion of prescribed opioid doses taken was 22%; and 97% of patients took ≤8 opioid doses postdischarge. Two patients were evaluated early due to poor pain control which improved with cast changes. Pain was well controlled or absent at follow-up in 97% of patients.

CONCLUSIONS

Pain is consistently well controlled after operative pediatric fractures. Nearly all were prescribed opioids, while acetaminophen/NSAIDs were inconsistently prescribed and used. Opioid prescriptions are written for 4 to 5 times the amount needed. Prescribing ≤8 doses of opioid is adequate for acute pain through POD5 in 97% of patients. Poorly controlled pain should prompt early evaluation for possible complications.

LEVEL OF EVIDENCE

Level II-prospective comparative study.

A Standardized Order-Set Improves Variability in Opioid Discharge Prescribing Patterns After Surgical Fixation of Pediatric Supracondylar Humerus Fractures

OBJECTIVE

To evaluate institutional opioid prescribing patterns following percutaneous fixation of pediatric supracondylar humerus fractures before and after implementation of a standardized discharge order set.

DESIGN

A retrospective review of patients who underwent closed reduction and percutaneous skeletal fixation of a Type II or III supracondylar humerus fracture in 2017 (prior to pain protocol implementation) and again in 2019 (after pain protocol implementation) SETTING: Single Tertiary Care Children's Hospital PARTICIPANTS: In total, 106 patients met inclusion criteria between years 2017 (n = 49) and 2019 (n = 57). Exclusion criteria included miscoded patients, open fractures, patients who presented with vascular injury or nerve palsy, polytrauma patients with multiple fractures in the same upper extremity, and supracondylar humerus fractures that underwent an open procedure.

RESULTS

There were no significant differences between inpatient pain scores (p = 0.91) and MDE prescribed (p = 0.75) between the 2 cohorts. In 2017, large variability was noted in day supply of opioids (0-11.4 days) and MDE (0-8.45 mg/kg), with significant differences between prescribing patterns of junior and senior level residents (mean day supply of opioids (p = 0.045), mean MDE prescribed on discharge (p = 0.001)). After implementation of a standardized opioid discharge order set, there was a tenfold increase in the number of patients discharged without an opioid prescription (2017: 4%, 2019: 44%). Additionally, any discrepancies between prescribing practices of junior and senior level residents were eliminated (mean day supply of opioids (p = 0.65), mean MDE prescribed on discharge (p = 0.69)).

CONCLUSIONS

The introduction of a standardized post-operative opioid discharge order set led to a 10-fold increase in the number of patients discharged without an opioid prescription. Additionally, the order set decreased the variability in the prescribing patterns of discharge opioid medications without change in pain control. The resident prescribing variability based upon level of experience resolved with the use of the order set.

The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey

INTRODUCTION

Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP).

METHODS

Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids.

RESULTS

569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP.

CONCLUSION

While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.

Opioid Fills in Children Undergoing Surgery From 2011 to 2014: A Retrospective Analysis of Relationships Among Age, Initial Days Supplied, and Refills

OBJECTIVE

The primary objective is to describe the relationship between the days supplied of postsurgical filled opioid prescriptions and refills.

BACKGROUND

The American College of Surgeons (ACS) has called for surgeons to alter opioid prescribing to counteract the opioid epidemic while simultaneously providing pain relief. However, there is insufficient evidence to inform perioperative prescribing guidelines and quality metrics in children.

METHODS

We performed a secondary data analysis of nationwide commercial claims from the Health Care Cost Institute (HCCI) data spanning 2010 and 2014. Based on initial opioid fill and refill rates for 11 common pediatric procedures, the refill analysis focused on anterior cruciate ligament repair, humerus fracture repair, cholecystectomy, posterior spinal fusion, and tonsillectomy.

RESULTS

There were 178,990 cases with a median age of 6. Overall, 48.5% of patients filled an opioid prescription between 30 days before surgery through 7 days after surgery, and 14.2% filled a second opioid prescription within 30 days. There was a significant negative relationship between days supplied in the initial prescription and probability of a refill for humerus fracture, spinal fusion, and tonsillectomy. The largest effect was seen for tonsillectomy, with the odds of having a refill decreasing by approximately 12% for each day supplied in the initial prescription (odds ratio 0.88, 95% confidence interval 0.87-0.89, P < 0.001).

CONCLUSIONS

Pediatric postoperative opioid-prescribing guidelines need to be procedure-specific and based on patient age. We provide the days supplied associated with a 20% probability of a refill by age to further guideline development.

Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use

OBJECTIVES

Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries.

DESIGN

Retrospective Cohort Study.

SETTING

Academic Level-1 Trauma Center.

PATIENTS

96 Patients with blunt or ballistic fractures.

INTERVENTION

Inpatient narcotic pain management after orthopaedic fracture management.

MAIN OUTCOME MEASUREMENTS

Morphine equivalent units (MEU).

RESULTS

Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption.

CONCLUSION

Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries.

LEVEL OF EVIDENCE

III.

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

BACKGROUND

Understanding which pediatric patients seek opioid refills is crucial as prescription opioid use in childhood is associated with an increased risk of future opioid misuse. Orthopaedic surgeons are optimally positioned to lead the charge in addressing the opioid epidemic. The aim of this study was to describe the incidence of and risk factors associated with requiring opioid refills after pediatric orthopaedic surgery in children.

METHODS

This retrospective case-control study included 1413 patients aged 0 to 18 years that underwent orthopaedic surgery at a single tertiary care children's hospital and were prescribed opioids at discharge. Using the state Prescription Drug Monitoring Program (PDMP) database, we determined which patients filled additional opioid prescriptions within 6 months following an orthopaedic procedure. Comparisons were made between patients that sought additional opioids and those that did not use bivariate analysis and binomial logistic regression.

RESULTS

In total, 31 (2.2%) patients sought additional opioid prescriptions a median 41 days postoperatively (range, 2 to 184). Nearly half of these patients obtained refills from providers outside of our institution, suggesting that previous reports using hospital records may underestimate its prevalence. Factors associated with requiring opioid refills included receiving hydromorphone [odds ratio (OR)=3.04, P=0.04] or methadone (OR=38.14, P<0.01) while inpatient, surgery on the axial skeleton (OR=5.42, P=0.01) or lower extremity (OR=2.49, P=0.04), and nonfracture surgery (OR=3.27, P=0.01). Patients who obtained additional opioids received significantly more opioids during their inpatient recovery (32.9 vs. 11.1 morphine equivalents, P<0.01).

CONCLUSIONS

Approximately 2% of children and families obtain additional opioids within 6 months of orthopaedic surgery. The volume of opioids during inpatient hospitalization may predict the need for opioid prescription refills after discharge. Clinicians should maximize efforts to achieve pain control with multimodal analgesia and opioid alternatives, and use caution when administering high-dose opioids during postoperative hospitalization.

LEVEL OF EVIDENCE

Level III-prognostic.

Decreased Prescribing of Postoperative Opioids in Pediatric ACL Reconstruction: Treatment Trends at a Single Center

BACKGROUND

Anterior cruciate ligament (ACL) injury is common in the pediatric population. Pain control after ACL reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Pain management practices are believed to have evolved in recent years to limit unnecessary exposure to risks associated with opioid use in this vulnerable population.

PURPOSE

To describe trends in postoperative opioid prescribing and assess factors including obtaining consent for opioid prescribing for minors that may have mitigated excessive prescription of opioids.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This is a retrospective review of a consecutive series of pediatric patients (<18 years) undergoing primary ACLR within an urban academic hospital system over a 5-year period (2014-2018). The study period included the gradual introduction of preoperative consenting for opioid use in minors as mandated by state law in 2016. Patient characteristics, surgical details, presence of a signed consent form to prescribe opioid medications, prescribed postoperative medications, prescriber, and indicators of inadequate pain control were collected. Univariate and multivariate analyses were performed to determine factors associated with reduced postoperative opioid prescribing.

RESULTS

This study included 687 patients with a mean age of 15.1 ± 1.9 years, with less than one-third of patients having preoperative consent forms to prescribe opioid medications. Postoperative prescribing trends demonstrated a decline in the number of opioid doses provided and increased utilization of nonopioid medications. Patients who received preoperative opioid counseling and signed a consent form were prescribed fewer opioids and had a smaller number of unscheduled contacts for poorly controlled pain. Univariate analyses identified multiple predictors of the number of opioid doses prescribed postoperatively. Obtaining preoperative consent to prescribe opioids and ambulatory surgery center location were found to be independent predictors of prescribed doses in the multivariate analysis.

CONCLUSION

The quantity of opioid medication prescribed for pain management after pediatric ACLR at our institution has declined in recent years. This appears to be, in part, related to state-mandated preoperative counseling about opioid use, signing of a consent form by the parent(s) or guardian(s) to prescribe opioids to minors, and encouragement toward the use of nonopioid medications when possible. Preoperative opioid use discussions in the pediatric population may be useful in reducing opioid overprescription and utilization in this population.

Outcomes of Preoperative Opioid Usage in Hip Arthroscopy: A Comparison With Opioid-Naïve Patients

PURPOSE

To compare postoperative outcomes between opioid-naïve patients and patients with a history of preoperative opioid usage undergoing hip arthroscopy. The secondary purpose is to determine whether preoperative opioid users consumed more oral morphine milligram equivalents than opioid-naïve patients following surgery.

METHODS

This is a single-center, retrospective analysis comparing outcomes and postoperative opioid usage between patients with and without a history of preoperative opioid use. Inclusion criteria included patients ≥18 years, Tönnis grade 0 or 1, imaging consistent with FAI or labral pathology, and a diagnosis of symptomatic FAI requiring hip arthroscopy. Patient outcomes were compared throughout a 2-year follow-up using the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS).

RESULTS

In total, 17 patients were evaluated in each cohort. The mean age of the study cohort and control cohort were 52.0 ± 9.4 years and 51.2 ± 12.2 years, respectively. Female patients were 58.8% (n = 10) of both cohorts. Non-naïve patients had a lower preoperative Nonarthritic Hip Score (P = .05) and a greater VAS at their 6-month and 1-year (P < .001) postoperative visits. Naïve patients reported greater modified Harris Hip Scores 2 years postoperatively (P < .001). The study cohort was prescribed greater levels of oral morphine equivalents at the postoperative 1-year visit (P = .05). Opioid-naïve patients were more likely to reach minimally clinically important difference and patient acceptable symptom state of VAS at a faster rate. At the 2-year follow-up, 11.8% of opioid-naïve patients continued to take opioids compared with 58.8% from the non-naïve group for persistent hip pain (P < .001).

CONCLUSIONS

We determined that preoperative opioid usage in patients undergoing hip arthroscopy is associated with inferior outcomes compared with opioid-naïve patients. In addition, preoperative opioid users are likely to continue the use of opioid medications postoperatively and at greater doses than opioid-naïve patients.

LEVEL OF EVIDENCE

3, retrospective comparative study.

Opioid Prescribing and Use After Pediatric Umbilical Hernia Repair

BACKGROUND

Opioid overuse is a concern in adult and pediatric populations. Physician education may improve appropriate opioid prescribing and patient instruction for use. Prescribing and use of opioids for pain control after pediatric umbilical hernia (UH) repair before and after surgeon education was evaluated. This is a substudy of a multi-institutional study assessing prescribing practice before and after surgeon education. This study further assessed patient prescription filling patterns and parent report of pain control.

METHODS

A retrospective study was performed evaluating children who underwent UH 6 months before and after an educational presentation on opioid use. Prescriptions, prescription fills, patient medication use, and pain control effectiveness were assessed. Adverse events were collected.

RESULTS

There were 78 subjects in the pre-education and 99 in the post-education group. Opioid prescribed changed from 98.7% to 61.6% (P < .0001), and nonopioid prescriptions increased following education (P = .0063). The number of opioid prescriptions filled decreased (P = .0296). There were limited data on opioid doses used and quality of pain control, but the post-education group showed good pain control. There was no difference in adverse events.

DISCUSSION

Surgeon education on the current opioid epidemic and strategies for opioid stewardship improves opioid prescribing and use without adversely impacting pain control or clinical outcome.

Opioid Prescribing and Use After Pediatric Umbilical Hernia Repair

BACKGROUND

Opioid overuse is a concern in adult and pediatric populations. Physician education may improve appropriate opioid prescribing and patient instruction for use. Prescribing and use of opioid for pain control after pediatric umbilical hernia repair (UH) before and after surgeon education was evaluated. This is a substudy of a multi-institutional study assessing prescribing practice before and after surgeon education. This study further assessed patient prescription filling pattern and parent report of pain control.

METHODS

A retrospective study was performed evaluating children who underwent UH 6 months before and after an educational presentation on opioid use. Prescriptions, prescription fills, patient medication use, and pain control effectiveness were assessed. Adverse events were collected.

RESULTS

There were 78 subjects in the pre- and 99 in the posteducation group. Opioid prescribed changed from 98.7% to 61.6% (P < .0001), and nonopioid prescriptions increased following education (P = .0063). The number of opioid prescriptions filled decreased (P = .0296). There were limited data on opioid doses used and quality of pain control, but the posteducation group showed good pain control. There was no difference in adverse events.

DISCUSSION

Surgeon education on current opioid epidemic and strategies for opioid stewardship improves opioid prescribing and use without adversely impacting pain control or clinical outcome.

Prospective Study of Acute Opioid Use After Adolescent Anterior Cruciate Ligament Reconstruction Shows No Effect From Patient- or Surgical-Related Factors

INTRODUCTION

Patient-reported pain scores and opioid use have not been quantified after outpatient adolescent anterior cruciate ligament reconstruction (ACLR).

METHODS

Patients aged 12 to 18 years undergoing primary isolated ACLR, with or without meniscal treatment, were prospectively recruited. Patients actively taking opioids or with previous extended use of opioids were excluded. Two orthopaedic surgeons performed ACLR and determined the use of a hamstring or bone-patellar tendon-bone autograft. For postoperative pain management, patients were prescribed 40 tablets of hydrocodone/acetaminophen 5/325 mg. Patients were instructed to document daily pill consumption and side effects through a daily log for 6 weeks. Patients completed the American Pain Society Patient Outcome Questionnaire at the end of weeks 1 and 6.

RESULTS

One hundred three patients were enrolled, with age: 12.5 to 18.9 years (mean 16.2 y ± 1.3), weight: 41.3 to 113.6 kg (mean 72.4 kg ± 17.2), and body mass index: 17.8 to 40.1 (mean 25.9 ± 4.9). Sixty-nine patients received a hamstring autograft, and 34 received a bone-patellar tendon-bone autograft. Fifty-six received additional meniscal procedures. The median number of postoperative opioids taken by patients was 17 (range 0 to 40). No notable differences were found in total pill consumption with regard to age, weight, body mass index, sex, block type, autograft type, or meniscal treatment at 1 week post-op or 6 weeks post-op. No correlation was found between the self-reported "worst pain in the past 24 hours" at the end of the first postoperative week or after 6 weeks (r = 0.112, P = 0.26, and r = 0.093, P = 0.36). No correlation was found between the level of satisfaction with pain treatment and total number of pills taken during the first postoperative week or at the end of 6 weeks (r = -0.090, P = 0.37, and r = -0.172, P = 0.08).

CONCLUSION

Patients take most pain medication during the first postoperative week after adolescent ACLR, although patient and surgical variables had no notable influence on pill consumption.

LEVEL OF EVIDENCE

Level IV, case series.

Prescription Drug Abuse Among Patients in Rural Dental Practices Reported by Members of the National Dental PBRN

PURPOSE

This study compared rural to nonrural dentists with respect to opioid prescribing practices, perceptions about prescription drug abuse among patients, and training relevant to pain management and addictions.

METHODS

A web-based, cross-sectional questionnaire was administered to practicing dentist members of the National Dental Practice-Based Research Network (PBRN; N = 822) and linked with network enrollment questionnaire data regarding practitioner demographics and practice characteristics. Pain management prescribing practices and perceptions regarding relevance and scope of addiction and drug diversion among patients were assessed. Rural practice was defined as a practice whose ZIP Code has more than 50% of its population in either a nonmetropolitan county and/or a rural Census tract.

FINDINGS

Rural dentists were significantly more likely than their nonrural counterparts to recommend nonsteroidal anti-inflammatory agents/acetaminophen in combination with prescribing an opioid [F (1,820) = 4.59, P = .03]. Compared to nonrural dentists, rural dentists were more likely to report that opioid abuse/diversion was a problem in their practices [χ² [1, n = 807] = 6.85, P < .001], were more likely to have suspected a patient of abuse or diversion [χ² [1, n = 807] = 10.12, P = .001], and were more likely to have refrained from prescribing due to suspicions of abuse or diversion [χ² [1, n = 807] = 12.49, P < .001].

CONCLUSION

Rural dentists may be disproportionately impacted by patients' opioid abuse and represent a viable target for educational outreach that encourages screening, identification, and referral of patients in need of drug abuse treatment.

Training experiences regarding pain management, addiction, and drug diversion of dentists enrolled in the National Dental Practice-Based Research Network

Background: The purpose of this study was to describe dentists' training experiences relevant to pain management, addiction, and prescription opioid drug diversion and examine associations between these training experiences and dentists' opioid prescribing practices. Methods: A Web-based, cross-sectional survey was conducted among practicing dentist members of the National Dental Practice-Based Research Network (PBRN; N = 822). The survey assessed pain management prescribing practices and training experiences related to pain management and assessment for addiction and drug diversion. Survey data were linked with National Dental PBRN Enrollment Questionnaire data regarding practitioner demographics and practice characteristics. Results: The majority of dentists (67%) reported prior training in pain management; however, a minority of dentists reported prior training regarding identification and assessment of drug abuse or addiction (48%) or identification of prescription drug diversion (25%). The majority of training experiences across all topics occurred through continuing dental education participation. Dental school training relevant to pain management, addiction, and identification of drug diversion was more prevalent among more recent dental school graduates. Training experiences were associated with prescribing practices. Conclusions: Results suggest that across multiple levels of training, many dentists are not receiving training specific to addiction assessment and identification of drug diversion. Such training is associated with greater consistency of risk mitigation implementation in practice.

Using Modern Neuroscience to Inform Opioid Use and Abuse Liability in Adolescents

Opioid abuse and overdosing have reached epidemic status in the United States, and this epidemic has profound negative effects on the lives of adolescents and their families. A combination of readily available opioids (including illicit opioids, such as heroin, and overprescribed prescription opioid-based painkillers) and an abuse vulnerability inherent to adolescence drives the problem. The pharmacology of opioids in the context of adolescent brain neurobiology helps explain the enhanced vulnerability to drug abuse experienced by the young. This report overviews these topics as they relate to orthopaedic procedures employed for adolescent patients.

The HECT ubiquitin E3 ligase Smurf2 degrades μ-opioid receptor 1 in the ubiquitin-proteasome system in lung epithelial cells

Opioids are widely used for relieving clinical acute or chronic pain. The biological effects of opioids are through activating μ-opioid receptor 1 (MOR1). Most studies have focused on the consequences of agonist-induced MOR1 phosphorylation, ubiquitination, and internalization. Agonist-mediated MOR1 degradation, which is crucial for receptor stability and responsiveness, has not been well studied. E3 ubiquitin-protein ligase SMURF2 (Smurf2), a homolog to E6AP carboxy terminus (HECT) ubiquitin E3 ligase, has been shown to regulate MOR1 ubiquitination and internalization; however, its role in MOR1 degradation has not been studied. Here, we demonstrate that Smurf2 mediates [d-Ala²,N-MePhe⁴,Gly⁵-ol]-enkephalin (DAMGO, an agonist of MOR1)-induced MOR1 ubiquitination and degradation. DAMGO decreased MOR1 levels in the ubiquitin-proteasome system. MOR1 was modified by a Lys48-linked polyubiquitin chain. Overexpression of Smurf2 induced MOR1 ubiquitination and accelerated DAMGO-induced MOR1 degradation, whereas downregulation of Smurf2 attenuated MOR1 degradation. Furthermore, DAMGO increased lung epithelial cell migration and proliferation, and the effect was attenuated by overexpressing Smurf2. Collectively, these data unveil that Smurf2 negatively regulates MOR1 activity by reducing its stability. We also demonstrate an unrevealed biological function of MOR1 in lung epithelial cells. DAMGO-MOR1 promote cell migration and proliferation in lung epithelial cells, suggesting a potential effect of DAMGO in lung repair and remodeling after lung injury.

Interdisciplinary Mitigation of Opioid Misuse in Musculoskeletal Patients

BACKGROUND

The opioid prescribing patterns of orthopedic surgeons have been shown to play a role in exacerbating rates of opioid misuse among post-surgical patients. Demonstrable success has been appreciated by combining policy-level approaches and clinical education-based strategies to inform patients of alternative modalities of post-operative analgesia.

QUESTIONS/PURPOSES

The purpose of this review was to address two questions: What are the most substantiated measures orthopedic surgeons can take to limit opioid misuse or addiction among their patients? What advantages are gained in orthopedic surgeons' collaborating with other healthcare professionals with influence over patients' post-operative opioid exposure?

METHODS

We searched two databases for articles on multidisciplinary policy-based solutions to mitigating the opioid overdose crisis among musculoskeletal patients. Articles produced from the search were searched for further evidence supporting the use of standardized clinical and administrative protocols in mitigating opioid misuse within this patient population. Successful approaches to mitigating misuse of opioids in this demographic were synthesized from recurring themes in the studies.

RESULTS

Multiple articles support orthopedic surgeons being aware of the risk factors for chronic opioid use among their patients, as well as multidisciplinary strategies involving orthopedic surgeons and other healthcare/governmental professionals to address the burden of the opioid crisis on surgical patients.

CONCLUSIONS

Addressing the misuse of opioids among orthopedic patients requires appropriate prescribing practices and long-term support of patients. Collaboration between surgeons and policymaking entities is recognized as an effective population-wide approach to preventing opioid dependence, misuse, and addiction.

Reduced Opioid Use After Surgeon-Administered Genicular Nerve Block for Anterior Cruciate Ligament Reconstruction in Adults and Adolescents

BACKGROUND

Pain management after anterior cruciate ligament reconstruction (ACLR) may pose a risk of prolonged opioid use.

QUESTIONS/PURPOSES

The purposes of this study in ACLR were to investigate the efficacy of a surgeon-administered local-regional block of specific genicular nerves on post-operative analgesia following ACLR and to quantify the outpatient opioid consumption and duration through the complete post-operative course.

METHODS

Prospectively, all patients undergoing primary ACLR by a single surgeon were studied over a 10-month period. Exclusion criteria consisted of history of pre-operative opioid use, revision surgery, multi-ligament surgery, allergy to oral opioids, and allergy to local anesthetic. ACLR was performed using autograft or allograft patellar tendon bone (PTB) graft under general anesthesia. At the conclusion of the procedure, all patients received a local anesthetic (bupivacaine 0.25%) injection by the surgeon including a unique circumferential genicular nerve and fat pad block performed based on anatomic landmarks without use of image guidance. Post-operatively, the quantity and duration of opioid use (hydrocodone 5 mg) and pain scores were recorded for 4 months prospectively. Statistical analysis was performed to evaluate risk factors for increased opioid use.

RESULTS

A single surgeon performed 75 ACLRs. After exclusions, a total of 70 patients were enrolled and followed prospectively. None were lost to follow-up. Total opioid consumption ranged from 0 to 30 tablets. The average number of opioid tablets used over the 4-month post-operative course was 5.5 (± 6.7). After surgery, 84% of patients took between 0 and 10 tablets and 21% of patients took no opioids throughout their entire post-operative course. The average duration of consumption was 2.6 days (± 3.1). No patients were taking opioids at the 6-week or 4-month follow-up. There were no refills required. No statistically significant differences were seen in regard to graft choice of autograft PTB (n = 48) vs allograft PTB (n = 22) in total opioid consumption or duration of use. In comparing adolescent (n = 31) versus adult (n = 39), no significant difference was seen in total opioid consumption or duration of use. All patients were satisfied with the post-operative pain management protocol.

CONCLUSION

Opioid use was unexpectedly low among patients undergoing ACLR after a surgeon-administered circumferential genicular nerve block and fat pad infiltration. With this protocol, the graft choice and patient age did not correlate with increased opioid use. These results could be useful in guiding post-operative opioid prescribing after ACLR.

Opioid Overprescription After Knee Arthroscopy and Related Surgery in Adolescents and Young Adults

PURPOSE

The purpose of this study was to compare the number of opioids prescribed with the amount of pain medication required after knee arthroscopy and related surgery in adolescent and young adult patients to determine the effectiveness of current pain-control practices at a single institution. The secondary purpose was to determine what demographic or surgical factors are associated with increased opioid intake.

METHODS

Adolescent and young adult patients who underwent knee arthroscopy and related surgery, including ligament reconstruction or tibial tubercle osteotomy, between May and August 2016 were provided pain-control logbooks in which they were asked to maintain a record of daily pain medication intake. The outcome of the study was defined as the total number of opioids consumed per patient.

RESULTS

One hundred patients returned completed logbooks, 56% of whom were female patients. The average age was 17.54 years (standard deviation [SD], 3.51 years). Most patients underwent an open procedure concurrent with knee arthroscopy (60%), underwent nerve block placement (51%), and underwent injection of local anesthesia (91%). Use of both intravenous acetaminophen and ketorolac during the perioperative period was also common (41%). Patients were prescribed an average of 50.98 oxycodone pills (SD, 12.50 pills) and reported consuming an average of 16.52 pills (SD, 13.94 pills), approximately 32.4% of those prescribed. Eleven percent never consumed opioids, and only 1 patient requested a refill during the 21-day postoperative period. Multivariate analysis showed that increased weight, longer surgery time, and increased diazepam use were most closely associated with increased opioid consumption.

CONCLUSIONS

After knee arthroscopy and related surgery, including ligament reconstruction or tibial tubercle osteotomy, adolescent and young adult patients are commonly overprescribed opioids, consuming on average only approximately one-third of those prescribed.

LEVEL OF EVIDENCE

Level IV, case series.

Opioid Prescribing Habits of General Versus Pediatric Surgeons After Uncomplicated Laparoscopic Appendectomy

BACKGROUND

Adolescents who use prescription opioids have an increased risk for future drug abuse and overdose, making them a high-risk population. Appendectomy is one of the most common surgical procedures in this age group, often requires opioid analgesia, and is performed by both pediatric and general surgeons. Prescription patterns comparing these two provider groups have not yet been evaluated; we hypothesize that general surgery providers prescribe more opioids for adolescent and young adult patients than do pediatric surgery providers.

METHODS

A retrospective chart review was conducted across a single health system consisting of four hospitals. All uncomplicated laparoscopic appendectomies performed between January 1, 2016 and August 14, 2017 on patients aged 7-20 were included for analysis. Any case coded for multiple procedures, identified as converted to open, or had a length of stay >48 h were excluded. The primary outcome measure was amount of opioid prescribed postoperatively. To standardize different formulations and types of analgesia prescribed, prescriptions were converted into oral morphine equivalents (OMEs). For reference, one 5 mg pill of oxycodone equals 7.5 OME. Linear regression was performed controlling for patient weight, gender, race, insurance status, provider type (pediatric versus general surgery), and provider level (resident, advanced practice provider, and attending).

RESULTS

A total of 336 pediatric laparoscopic appendectomies were analyzed, 148 by general surgeons and 188 by pediatric surgeons. Pediatric surgeons prescribed less opioid than general surgeons overall (59 OME versus 90 OME, P < 0.0001). For patients aged <13 y, there was no significant difference between pediatric (26 OME) and general (37 OME, P = 0.8921) surgeons. However, for the age group 13-20 y, pediatric surgeons prescribed 25% less opioid than general surgeons (90 OME versus 112.5 OME, P < 0.0001). Regression analysis demonstrated that being cared for by a general surgery service (+24.1 OME [95% confidence interval 9.8-38.3]) was associated with high prescribing, whereas having Medicaid was associated with lower prescription amounts (-16.4 OME [95% confidence interval -32.5 to -0.3]).

CONCLUSIONS

After an uncomplicated laparoscopic appendectomy, general surgeons prescribe significantly more opioid to adolescent patients than do pediatric surgeons, even when controlling for age and weight. One substantial and modifiable contributor of the opioid epidemic is the amount of opioid prescribed. The variability of prescribing habits to adolescents and young adults demonstrates a clear need for increased education and guidelines on this topic, especially for surgeons who do not frequently treat the younger and more vulnerable population.

Current State of the Opioid Epidemic as it Pertains to Pediatric Orthopaedics From the Advocacy Committee of the Pediatric Orthopaedic Society of North America

INTRODUCTION

The opioid epidemic in the United States has reached crisis proportions. Urgent response is needed. Hydrocodone in combination with acetaminophen is the most prescribed drug in the United States. The most common source of opioids available for misuse is the unused portions of postoperative prescriptions. Among high school seniors, 80% of those who reported nonmedical use of prescription opioids previously had legitimate prescriptions but recreationally used leftover doses. Roughly one-quarter of patients do not take any of their postoperatively prescribed opioids and the remainder take one-third to two-thirds of the prescribed doses.

METHODS

A summary of the literature is presented beginning from historical perspective to current status and pertinent strategies in dealing with this complicated problem. This review includes data from an electronic survey of the members of the Pediatric Orthopaedic Society of North America (POSNA) with regard to the prescriptions they would provide for 7 treatment scenarios.

RESULTS

Strategies for the preoperative, intraoperative, and postoperative phases of management of pain as well as strategies for education, research, and advocacy are presented. The Pediatric Orthopaedic Society of North America survey yielded 264 respondents. The 3 most commonly used opioid medications were hydrocodone, oxycodone, and acetaminophen with codeine, in that order, for most of the scenarios. The time period covered by postoperative prescriptions varied considerably.

CONCLUSIONS

The magnitude of this problem is overwhelming. Education of care providers, patients and families, standardization of narcotic prescribing practices which incorporate patient characteristics, and appropriate plans for disposal of unused narcotics are immediate concepts to consider in correcting this problem. Long-term issues to tackle will be changing patient a family expectations, legislation, and obtaining additional resources directed towards this issue.

Persistent Opioid Use Among Pediatric Patients After Surgery

BACKGROUND

Despite efforts to reduce nonmedical opioid misuse, little is known about the development of persistent opioid use after surgery among adolescents and young adults. We hypothesized that there is an increased incidence of prolonged opioid refills among adolescents and young adults who received prescription opioids after surgery compared with nonsurgical patients.

METHODS

We performed a retrospective cohort study by using commercial claims from the Truven Health Marketscan research databases from January 1, 2010, to December 31, 2014. We included opioid-naïve patients ages 13 to 21 years who underwent 1 of 13 operations. A random sample of 3% of nonsurgical patients who matched eligibility criteria was included as a comparison. Our primary outcome was persistent opioid use, which was defined as ≥1 opioid prescription refill between 90 and 180 days after the surgical procedure.

RESULTS

Among eligible patients, 60.5% filled a postoperative opioid prescription (88 637 patients). Persistent opioid use was found in 4.8% of patients (2.7%-15.2% across procedures) compared with 0.1% of those in the nonsurgical group. Cholecystectomy (adjusted odds ratio 1.13; 95% confidence interval, 1.00-1.26) and colectomy (adjusted odds ratio 2.33; 95% confidence interval, 1.01-5.34) were associated with the highest risk of persistent opioid use. Independent risk factors included older age, female sex, previous substance use disorder, chronic pain, and preoperative opioid fill.

CONCLUSIONS

Persistent opioid use after surgery is a concern among adolescents and young adults and may represent an important pathway to prescription opioid misuse. Identifying safe, evidence-based practices for pain management is a top priority, particularly among at-risk patients.