Trends in Postoperative Opioid Prescribing in Outpatient Pediatric Surgery

Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020

INTRODUCTION

The United States currently faces an epidemic of opioid misuse which extends to adolescent surgical populations. Opioid prescriptions after surgery are associated with persistent opioid use and serve as a reservoir for diversion. However, it is unclear what proportion of opioid prescriptions are surgical, and little is known about trends in opioid prescription rates associated with surgery in adolescents in the United States. This study aims to describe national trends in postsurgical opioid prescription rates over time among adolescents in the United States.

METHODS

We conducted a population-based cross-sectional analysis of data captured in the Medical Expenditure Panel Survey (MEPS) from 2015 to 2020. MEPS classified adolescents 10-19 years of age (n = 26 909) as having a surgical procedure if they had any inpatient, outpatient, or emergency department visit during which a surgical procedure was performed.

RESULTS

Mean age (SD) of the sample was 14.4 (0.01) years. Sociodemographic characteristics were representative of the USA adolescent population. In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%-3.7%, p < .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020).

DISCUSSION

Opioid prescription rates associated with surgery remained stable between 2015 and 2020 in the United States, despite significant decreases in prescribing among nonsurgical populations. Surgery is now a leading source of medical prescribed opioids among adolescents. Secondary findings included a stable trend in surgery utilization between 2015 and 2020, as well as continued racial disparities, both in terms of surgery utilization and opioid prescribing.

CONCLUSION

The large number of adolescents being prescribed opioids for surgery in the USA each year, suggests there is a need for national guidelines aimed at adolescent opioid use, similar to the recent CDC guidelines aimed at adult opioid use.

Variation in opioid filling after same-day breast surgery in Ontario, Canada: a population-based cohort study

BACKGROUND

Postoperative pain management practices in breast surgery are variable, with recent evidence that approaches for minimizing or sparing opioids can be successfully implemented. We describe opioid filling and predictors of higher doses in patients undergoing same-day breast surgery in Ontario, Canada.

METHODS

In this retrospective population-based cohort study, we used linked administrative health data to identify patients aged 18 years or older who underwent same-day breast surgery from 2012 to 2020. We categorized procedure types by increasing invasiveness of surgery: partial, with or without axillary intervention (P ± axilla); total, with or without axillary intervention (T ± axilla); radical, with or without axillary intervention (R ± axilla); and bilateral. The primary outcome was filling an opioid prescription within 7 or fewer days after surgery. Secondary outcomes were total oral morphine equivalents (OMEs) filled (mg, median and interquartile range [IQR]) and filling more than 1 prescription within 7 or fewer days after surgery. We estimated associations (adjusted risk ratios [RRs] and 95% confidence intervals [CIs]) between study variables and outcomes in multivariable models. We used a random intercept for each unique prescriber to account for provider-level clustering.

RESULTS

Of the 84 369 patients who underwent same-day breast surgery, 72% (n = 60 620) filled an opioid prescription. Median OMEs filled increased with invasiveness (P ± axilla = 135 [IQR 90-180] mg; T ± axilla = 135 [IQR 100-200] mg; R ± axilla = 150 [IQR 113-225] mg, bilateral surgery = 150 [IQR 113-225] mg; p < 0.0001). Factors associated with filling more than 1 opioid prescription were age 30-59 years (v. age 18-29 yr), increased invasiveness (RR 1.98, 95% CI 1.70-2.30 bilateral v. P ± axilla), Charlson Comorbidity Index ≥ 2 versus 0-1 (RR 1.50, 95% CI 1.34-1.69) and malignancy (RR 1.39, 95% CI 1.26-1.53).

INTERPRETATION

Most patients undergoing same-day breast surgery fill an opioid prescription within 7 days. Efforts are needed to identify patient groups where opioids may be successfully minimized or eliminated.

Outpatient Opioid Prescriptions are Associated With Future Substance Use Disorders and Overdose Following Adolescent Trauma

OBJECTIVE

This study aims to determine if outpatient opioid prescriptions are associated with future SUD diagnoses and overdose in injured adolescents 5 years following hospital discharge.

SUMMARY OF BACKGROUND DATA

Approximately, 1 in 8 adolescents are diagnosed with an SUD and 1 in 10 experience an overdose in the 5 years following injury. State laws have become more restrictive on opioid prescribing by acute care providers for treating pain, however, prescriptions from other outpatient providers are still often obtained.

METHODS

This was a retrospective cohort study of patients ages 12-18 admitted to 2 level I trauma centers. Demographic and clinical data contained in trauma registries were linked to a regional database containing 5 years of electronic health records and prescription data. Regression models assessed whether number of outpatient opioid prescription fills after discharge at different time points in recovery were associated with a new SUD diagnosis or overdose, while controlling for demographic and injury characteristics, and depression and posttraumatic stress disorder diagnoses.

RESULTS

We linked 669 patients (90.9%) from trauma registries to a regional health information exchange database. Each prescription opioid refill in the first 3 months after discharge increased the likelihood of new SUD diagnoses by 55% (odds ratio: 1.55, confidence interval: 1.04-2.32). Odds of overdose increased with ongoing opioid use over 2-4 years post-discharge ( P = 0.016-0.025).

CONCLUSIONS

Short-term outpatient opioid prescribing over the first few months of recovery had the largest effect on developing an SUD, while long-term prescription use over multiple years was associated with a future overdose.

Dispensed Opioid Prescription Patterns, by Racial/Ethnic Groups, Among South Carolina Medicaid-Funded Children Experiencing Limb Fracture Injuries

OBJECTIVE

To examine dispensed opioid prescription patterns for limb fractures across racial/ethnic groups in a pediatric population.

METHODS

We used South Carolina's Medicaid claims data 2000 to 2018 for pediatric limb fracture cases (under age 19) discharged from the emergency department. The key independent variable was the child's race/ethnicity. The outcomes were: 1) whether the patient had a dispensed opioid prescription; and 2) whether dispensed opioid supply was longer than 5 days among cases with any dispensed opioid prescriptions. Logistic regression models were used to test the association between race/ethnicity and the outcomes. Covariates included age-at-service, gender, service year, and having multiple fracture injuries.

RESULTS

Compared with non-Hispanic White cases (NHW), the odds of receiving dispensed opioid prescriptions were lower for cases of non-Hispanic Black (NHB) (OR = 0.73; 95% confidence interval [CI]: 0.71, 0.75), Asian (OR = 0.69; CI: 0.53, 0.90), Other/Unknown (OR = 0.86; CI: 0.80, 0.92), and Hispanic (OR = 0.84; CI: 0.79, 0.90) race/ethnicity. The odds of receiving >5 days of dispensed opioid prescription supply did not differ significantly among race/ethnic categories.

CONCLUSIONS

Our study confirms previous findings that as compared to NHW, the NHB children were less likely to receive dispensed opioid prescriptions. Also, it reveals that the different minority race/ethnic groups are not homogenous in their likelihoods of receiving dispensed opioid prescriptions after a limb fracture compared to NHW, findings underreported in previous studies. Children in the Other/Unknown race/ethnicity category have prescribing patterns different from those of other minority race/ethnic groups and should be analyzed separately.

Opioid reduction and elimination in pediatric surgical patients

INTRODUCTION

Opioid overuse is a national concern. Mitigation strategies include judicious prescribing and encouragement of non-opioid therapies. This quality improvement project aimed to identify physician opioid prescribing and patient usage patterns at a pediatric academic center.

METHODS

Patients who underwent same-day general, orthopedic, or plastic surgery procedures were contacted 7 - 28 days post-operatively. Inquiries were made about opioid usage, non-opioid strategies, and overall pain management satisfaction. A subset of general surgery patients not prescribed opioids was compared to those prescribed opioids.

RESULTS

Between August 2017 - May 2020, 558 surveys were obtained. There was a significant increase in the use of non-opioid therapies between 2017 and 2020 (83.5% vs 97%, p=0.04). Almost all patients' opioid prescriptions were filled; however, 78-98% had leftover opioids. Only 20-25% disposed the excess opioids. In subset analysis of general surgery patients, no inguinal hernia or orchiopexy patient who was discharged without opioids required opioids later. More non-opioid patients used other therapies (acetaminophen, heat (p=0.03)); however, pain management satisfaction was higher in the opioid group (99% vs 94%, p=0.01).

CONCLUSION

While our opioid prescribing has decreased, physicians are still prescribing more opioids than patients require. Further education on non-opioid pain therapies and proper disposal of opioids are needed.

LEVEL OF EVIDENCE

III TYPE OF STUDY: prospective quality improvement study.

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.

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.

Effective Reduction in Opioid Prescriptions for Ambulatory Lesion Excisions in Pediatric Patients

Childhood opioid consumption is potentially deleterious to cognitive development and may predispose children to later addiction. Opioids are frequently prescribed for outpatient surgery but may not be necessary for adequate pain control. We aimed to reduce opioid prescriptions for outpatient pediatric skin and soft tissue lesion excisions using quality improvement (QI) methods.

METHODS

A multidisciplinary team identified drivers for opioid prescriptions. Interventions were provider education, improving computer order set defaults, and promoting non-narcotic pain control strategies and patient-family education. Outcomes included percentage of patients receiving opioid prescriptions and patient-satisfaction scores. Data were retrospectively collected for 3 years before the QI project and prospectively tracked over the 8-month QI period and the following 18 months.

RESULTS

The percentage of patients receiving an opioid prescription after outpatient skin or soft tissue excision dropped significantly from 18% before intervention to 6% at the end of the intervention period. Patient-reported satisfaction with pain control improved following the QI intervention. Satisfaction with postoperative pain control was independent of closure size or receipt of a postoperative opioid prescription. Intraoperative use of lidocaine or bupivacaine significantly decreased the incidence of postoperative opioid prescription in both bivariate and multivariate analyses. Results were maintained at 18 months after the conclusion of the QI project.

CONCLUSION

Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.

Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative

INTRODUCTION

Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms.

OBJECTIVE

To measure the efficacy of a quality improvement initiative aimed to reduce post-operative opioids for pain management in a large pediatric surgical cohort.

STUDY DESIGN

Patients undergoing ambulatory pediatric urologic surgery at a tertiary children's hospital between July 2016 to June 2019 were analyzed. Structured physician peer-to-peer comparisons, electronic health record redesign and a standardized pain management protocol were implemented. Rate of opioid prescriptions per month, utilization of non-opioid analgesia, unplanned encounters in the emergency department and/or office during implementation were aggregated. Opioid doses and prescribed opioid days before and after protocol implementation were analyzed. A subcohort, from October-December 2018 was administered a patient-reported outcome questionnaire focused on pain management and return to baseline activity.

RESULTS

A total of 6684 consecutive outpatient urologic cases were included (median age = 3.3 years old (IQR 0.9-9.2) and 92.3% male). Comparing 6 months pre-intervention and the post-intervention latest 6 month intervals, opioid prescription rate decreased from 43.9% to 2.3% (p < 0.001). Additionally, non-opioid analgesia with ketorolac increased from 30.7% to 50.6% (p < 0.001). Concurrently, no differences in the rate of office visits within 5 days, overall ED visits, ED visits for pain or for bleeding within 30 days after implementation were identified. Between October to December 2018, 373 cases were performed and a Patient-Reported Outcome (PRO) questionnaire was completed for 128 of those patients (34%). Families reported a low patient pain score of 3.7 (SD 2.4) and a rapid postoperative recovery time of a median 2 (IQR 1-4) days to full resumption of pre-operative level of activity. High satisfaction with opioid reduction in post-operative pain management was reported (median score of 10 (IQR 8-10)).

CONCLUSION

Opioid prescriptions and utilization may be minimized without increasing unplanned encounters or adversely affecting quality of life. The QI framework utilized in this process can be implemented to reduce opioid exposure in other surgical patient populations.