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Chen YH, Xenitidis A, Hoffmann P, Matthews L, Padmanabhan SG, Aravindan L, Ressler R, Sivam I, Sivam S, Gillispie CF, Sadhasivam S. Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia. Expert Rev Clin Pharmacol 2024; 17:455-465. [PMID: 38626303 PMCID: PMC11116045 DOI: 10.1080/17512433.2024.2343915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 04/12/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder. AREAS COVERED Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic. EXPERT OPINION The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Paul Hoffmann
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leslie Matthews
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Ruth Ressler
- Department of Biochemistry and Molecular Biology, The College of Wooster, Wooster, Ohio, USA
| | - Inesh Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Sahana Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Chase F. Gillispie
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia 25701
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Wedoff M, Brinton DL, Maldonado L, Andrews AL, Simpson AN, Basco WT. Persistent Opioid Use Following Pediatric Nonfatal Firearm Injury. Acad Pediatr 2024:S1876-2859(24)00059-7. [PMID: 38437979 DOI: 10.1016/j.acap.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 03/06/2024]
Abstract
OBJECTIVE Firearms are a major cause of pediatric injury. An analysis of opioid use following pediatric firearm injury has not previously been reported. Our objective was to determine the prevalence and factors associated with persistent opioid use among pediatric nonfatal firearm injury victims. METHODS We performed a retrospective cohort study using 2015-18 claims data from the Merative MarketScan Multi-State Medicaid and Commercial Databases, utilizing International Classification of Diseases, Tenth Revision codes for firearm injury and National Drug Codes for opioids. Dispensed opioid claims were used as a proxy for opioid use. Opioid exposure was defined both dichotomously and continuously (by the total number of opioid days prescribed) in the 30 days following discharge from firearm injury index encounter. Persistent opioid use was defined as ≥1 opioid claim(s) in the 90 to 270 days following index encounter. Multivariable logistic regression analysis was performed to determine whether covariates of interest were associated with greater odds of persistent opioid use. RESULTS Our cohort consisted of 2110 children who experienced nonfatal firearm injury (mean age 13.5, 80.9% male, 79.5% Medicaid) with 608 children (28.8%) exposed to opioids. Of patients exposed to opioids, 10.4% developed persistent opioid use. In adjusted analyses, each opioid day dispensed during the exposure period represented 5% greater odds of experiencing persistent opioid use. CONCLUSIONS Clinicians caring for children injured by firearms should be aware of the risk of developing persistent opioid use and balance that risk with the need to sufficiently control pain.
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Affiliation(s)
- Michael Wedoff
- Department of Pediatrics (M Wedoff and WT Basco), College of Medicine, Medical University of South Carolina, Charleston.
| | - Daniel L Brinton
- Department of Healthcare Leadership and Management (DL Brinton and L Maldonado), College of Health Professions, Medical University of South Carolina, Charleston.
| | - Lizmarie Maldonado
- Department of Healthcare Leadership and Management (DL Brinton and L Maldonado), College of Health Professions, Medical University of South Carolina, Charleston.
| | - Annie L Andrews
- Department of Pediatrics (A Andrews), The George Washington School of Medicine, DC.
| | - Annie N Simpson
- Real World Evidence (A Simpson), PrecisionHEOR, Boston, Mass.
| | - William T Basco
- Department of Pediatrics (M Wedoff and WT Basco), College of Medicine, Medical University of South Carolina, Charleston.
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Tuttnauer A, Atias D, Reznik O, Shomron N, Obolski U. Opioid trends and risk factors for sustained use among children and adolescents in Israel: a retrospective cohort study. Pain 2024:00006396-990000000-00491. [PMID: 38193827 DOI: 10.1097/j.pain.0000000000003153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/17/2023] [Indexed: 01/10/2024]
Abstract
ABSTRACT Despite growing global concern over opioids, little is known about the epidemiology of opioid use in children and adolescents. This retrospective study investigated opioid use trends and identified risk factors associated with sustained opioid use among outpatient children and adolescents in Israel. Electronic health records of 110,955 children and adolescents were used to establish opioid purchase trends in outpatient settings between 2003 and 2021. Of these, data from 2012 to 2021, n = 32,956, were included in a Cox proportional hazards analysis to identify demographic, clinical, and pharmacological risk factors for sustained opioid use. An increase in opioid use was observed, with a notable rise among strong opioids, peripheral areas, and noncancer patients. Prevalence of sustained opioid users was approximately 2.5%. Risk factors with significant adjusted hazard ratios for sustained use included history of frequent doctor visits 1.82 (95% CI [1.50-2.22]) and drug purchases 1.30 (95% CI [1.07-1.58]), malignancy 1.50 (95% CI [1.07-2.09]), history of cardiovascular (1.44 (95% CI [1.04-1.98]) and pain-related conditions 1.34 (95% CI [1.14-1.58]), and different opioid substances (relative to codeine use): tramadol 2.38 (95% CI [1.73-3.27]), oxycodone 4.29 (95% CI [3.00-6.16]), and "other strong opioids" 6.05 (95% CI [3.59-10.2]). Awareness of observed increase in opioid purchases is crucial for doctors and public health practitioners. Additional monitoring and secondary prevention of children and adolescents possessing the identified risk factors should facilitate where appropriate reducing sustained opioid use when it is unnecessary.
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Affiliation(s)
- Aviv Tuttnauer
- Department of Anesthesia, Pain Treatment Service, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Dor Atias
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Reznik
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Data Research Center, Research Authority, Schneider Children's Medical Center of Petach Tikva, Israel, Israel
| | - Noam Shomron
- Faculty of Medicine, Edmond J Safra Center for Bioinformatics, Sagol School of Neurosceince, Djerassi Institute of Oncology, Innovaiton Labs (TILabs), Tel-Aviv University, Tel Aviv, Israel
| | - Uri Obolski
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Porter School of the Environment and Earth Sciences, Faculty of Exact Sciences, Tel Aviv University, Tel Aviv, Israel
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Grutman AJ, Stewart C, Able C, Agrawal P, Galansky L, Gabrielson A, Haney N, Kohn TP, Crigger CB. Postoperative Opioid Prescribing in Adolescents and Young Adults After Urologic Procedures Is Associated With New Persistent Opioid Use Disorder: A Large Claims Database Analysis. Urology 2023; 182:211-217. [PMID: 37696308 DOI: 10.1016/j.urology.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To assess the risk of persistent opioid use following various urologic procedures in adolescents and young adults. MATERIALS AND METHODS The TriNetX LLC Diamond Network was queried for patients aged 13-21years who underwent pyeloplasty, hypospadias repair, inguinal hernia repair, inguinal orchiopexy, hydrocelectomy, or circumcision. Cohorts of patients prescribed and not prescribed postoperative opioids were created and propensity-matched for age, race/ethnicity, psychiatric diagnoses, and preoperative pain diagnoses. The primary outcome was new persistent opioid use, defined as new opioid use 3-9months after index procedure without another surgery requiring anesthesia during the postoperative timeframe. RESULTS Of 32,789 patients identified, 66.0% received a postoperative opioid prescription. After propensity score matching for each procedure, 18,416 patients were included: 197 for pyeloplasty, 469 for hypospadias repair, 1818 for inguinal hernia repair, 2664 for inguinal orchiopexy, 534 for hydrocelectomy, and 3526 for circumcision. Overall, 0.41% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 1.69% of patients who received postoperative opioids developed new persistent opioid use (P < .05). Patients prescribed postoperative opioids had statistically higher odds of developing new persistent opioid use for hypospadias repair (RR: 17.0; 95% CI: 2.27-127.2), inguinal orchiopexy (RR: 3.46; 95% CI: 1.87-6.4), inguinal hernia repair (RR: 2.18; 95% CI: 1.07-4.44), and circumcision (RR: 4.83; 95% CI: 2.60-8.98). CONCLUSION The use of postoperative opioids after urological procedures in adolescents and young adults is associated with a significant risk of developing new persistent opioid use.
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Affiliation(s)
| | - Courtney Stewart
- University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX
| | - Corey Able
- University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX
| | | | - Logan Galansky
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Gabrielson
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nora Haney
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Taylor P Kohn
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chad B Crigger
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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Martin LD, Franz AM, Rampersad SE, Ojo B, Low DK, Martin LD, Hunyady AI, Flack SH, Geiduschek JM. Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Paediatr Anaesth 2023; 33:699-709. [PMID: 37300350 DOI: 10.1111/pan.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.
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Affiliation(s)
- Lynn D Martin
- Department of Anesthesiology & Pain Medicine and Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Amber M Franz
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sally E Rampersad
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Bukola Ojo
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Daniel K Low
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Lizabeth D Martin
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Agnes I Hunyady
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sean H Flack
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeremy M Geiduschek
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
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Chen O, Cadwell JB, Matsoukas K, Hagen J, Afonso AM. Perioperative gabapentin usage in pediatric patients: A scoping review. Paediatr Anaesth 2023; 33:598-608. [PMID: 37073498 PMCID: PMC10464522 DOI: 10.1111/pan.14674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 03/08/2023] [Accepted: 04/01/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population. DATA SOURCES Pubmed, CINAHL, Embase, Scopus, and Web of Science Review. METHODS This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results. RESULTS Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance. CONCLUSIONS The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.
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Affiliation(s)
- Olivia Chen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joshua B. Cadwell
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Konstantina Matsoukas
- Medical Library, Information Systems, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John Hagen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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Thapa I, De Souza E, Ward A, Bambos N, Anderson TA. Association of Common Pediatric Surgeries With New Onset Chronic Pain in Patients 0-21 Years of Age in the United States. THE JOURNAL OF PAIN 2023; 24:320-331. [PMID: 36216129 DOI: 10.1016/j.jpain.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 11/07/2022]
Abstract
Chronic pain (CP) is a major public health issue. While new onset CP is known to occur frequently after some pediatric surgeries, its incidence after the most common pediatric surgeries is unknown. This retrospective cohort study used insurance claims data from 2002 to 2017 for patients 0 to 21 years of age. The primary outcome was CP 90 to 365 days after each of the 20 most frequent surgeries in 5 age categories (identified using CP ICD codes). Multivariable logistic regression identified surgeries and risk factors associated with CP after surgery. A total of 424,590 surgical patients aged 0 to 21 were included, 22,361 of whom developed CP in the 90 to 365 days after surgery. The incidences of CP after surgery were: 1.1% in age group 0 to 1 years; 3.0% in 2 to 5 years; 5.6% in 6 to 11 years; 10.1% in 12 to 18 years; 9.9% in 19 to 21 years. Some surgeries and patient variables were associated with CP. Approximately 1 in 10 adolescents who underwent the most common surgeries developed CP, as did a striking percentage of children in other age groups. Given the long-term consequences of CP, resources should be allocated toward identification of high-risk pediatric patients and strategies to prevent CP after surgery. PERSPECTIVE: This study identifies the incidences of and risk factors for chronic pain after common surgeries in patients 0 to 21 years of age. Our findings suggest that resources should be allocated toward the identification of high-risk pediatric patients and strategies to prevent CP after surgery.
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Affiliation(s)
- Isha Thapa
- Department of Management Science and Engineering, Stanford University, Stanford, California.
| | - Elizabeth De Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Andrew Ward
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Nicholas Bambos
- Department of Electrical Engineering and Department of Management Science & Engineering, Stanford University, Stanford, California
| | - Thomas Anthony Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Cummings Joyner AK, King MR, Safranek C, Parvathinathan G, De Souza E, Anderson TA. Health Care Burden Associated With Adolescent Prolonged Opioid Use After Surgery. Anesth Analg 2023; 136:317-326. [PMID: 35726884 DOI: 10.1213/ane.0000000000006111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prolonged opioid use after surgery (POUS), defined as the filling of at least 1 opioid prescription filled between 90 and 180 days after surgery, has been shown to increase health care costs and utilization in adult populations. However, its economic burden has not been studied in adolescent patients. We hypothesized that adolescents with POUS would have higher health care costs and utilization than non-POUS patients. METHODS Opioid-naive patients 12 to 21 years of age in the United States who received outpatient prescription opioids after surgery were identified from insurance claim data from the Optum Clinformatics Data Mart Database from January 1, 2003, to June 30, 2019. The primary outcomes were total health care costs and visits in the 730-day period after the surgical encounter in patients with POUS versus those without POUS. Multivariable regression analyses were used to determine adjusted health care cost and visit differences. RESULTS A total of 126,338 unique patients undergoing 132,107 procedures were included in the analysis, with 4867 patients meeting criteria for POUS for an incidence of 3.9%. Adjusted mean total health care costs in the 730 days after surgery were $4604 (95% confidence interval [CI], $4027-$5181) higher in patients with POUS than that in non-POUS patients. Patients with POUS had increases in mean adjusted inpatient length of stay (0.26 greater [95% CI, 0.22-0.30]), inpatient visits (0.07 greater [95% CI, 0.07-0.08]), emergency visits (0.96 greater [95% CI, 0.89-1.03]), and outpatient/other visits (5.78 greater [95% CI, 5.37-6.19]) in the 730 days after surgery ( P < .001 for all comparisons). CONCLUSIONS In adolescents, POUS was associated with increased total health care costs and utilization in the 730 days after their surgical encounter. Given the increased health care burden associated with POUS in adolescents, further investigation of preventative measures for high-risk individuals and additional study of the relationship between opioid prescription and outcomes may be warranted.
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Affiliation(s)
| | - Michael R King
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Conrad Safranek
- Department of Biology, Stanford University, Stanford, California
| | - Gomathy Parvathinathan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Elizabeth De Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - T Anthony Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Cina RA, Ward RC, Basco WT, Taber DJ, Gebregziabher M, McCauley JL, Lockett MA, Moran WP, Mauldin PD, Ball SJ. Incidence and patterns of persistent opioid use in children following appendectomy. J Pediatr Surg 2022; 57:912-919. [PMID: 35688690 DOI: 10.1016/j.jpedsurg.2022.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/12/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children. STUDY DESIGN A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis. RESULTS 1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). CONCLUSION Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert A Cina
- Department of Surgery, The Medical University of South Carolina, 10 McClennan Banks Drive, MSC 918
- SJCH 2190, Charleston, SC 29425, USA.
| | - Ralph C Ward
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - William T Basco
- Department of Pediatrics, The Medical University of South Carolina, Charleston, SC, USA
| | - David J Taber
- Department of Surgery, The Medical University of South Carolina, 10 McClennan Banks Drive, MSC 918
- SJCH 2190, Charleston, SC 29425, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Science, The Medical University of South Carolina, Charleston, SC, USA
| | - Mark A Lockett
- Department of Surgery, The Medical University of South Carolina, 10 McClennan Banks Drive, MSC 918
- SJCH 2190, Charleston, SC 29425, USA
| | - William P Moran
- Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D Mauldin
- Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Sarah J Ball
- Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
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Kennedy H, Malik Z, Patel D. Persistent postoperative prescribing of opioids: a warning from the west? Comment on Br J Anaesth 2021; 126: 1192-9. Br J Anaesth 2021; 127:e202-e204. [PMID: 34561050 DOI: 10.1016/j.bja.2021.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Helen Kennedy
- North West School of Anaesthesia, Health Education England North West, Manchester, UK.
| | - Zeeshan Malik
- North West School of Anaesthesia, Health Education England North West, Manchester, UK
| | - Davandra Patel
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK
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Lee HM, Park JH, Park SJ, Choi H, Lee JR. Comparison of Monotherapy Versus Combination of Intravenous Ibuprofen and Propacetamol (Acetaminophen) for Reduction of Postoperative Opioid Administration in Children Undergoing Laparoscopic Hernia Repair: A Double-Blind Randomized Controlled Trial. Anesth Analg 2021; 133:168-175. [PMID: 33181557 DOI: 10.1213/ane.0000000000005284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Extensive efforts have been made toward reducing postoperative opioid use in children. In this study, we assessed whether propacetamol, or a nonsteroidal anti-inflammatory drug (NSAID), or their combination could effectively reduce opioid use in children after laparoscopic inguinal hernia repair. METHODS This randomized, double-blind clinical trial included 159 children aged 6 months to 6 years. Children were allocated into 1 of the following 3 groups: group I was treated with 10 mg·kg-1 ibuprofen, group P was treated with 30 mg·kg-1 propacetamol, and group I + P was treated with both drugs in their respective concentrations. If the face-legs-activity-crying-consolability (FLACC) score was ≥4 during the postanesthesia care unit stay, 1.0 µg·kg-1 fentanyl was administered as a rescue analgesic. The number of patients who received rescue fentanyl in the postanesthesia care unit was defined as the primary outcome; this was analyzed using the χ2 test. The secondary outcomes included the FLACC and the parents' postoperative pain measure (PPPM) scores until the 24-hour postoperative period. RESULTS Among the 144 enrolled patients, 28.6% in group I, 66.7% in group P, and 12.8% in group I + P received rescue fentanyl in the postanesthesia care unit (P < .001). The highest FLACC score was lower in group I + P than in either group I or P (P = .007 and P < .001, respectively). Group I + P presented significantly lower PPPM scores than group P at 4 and 12 hours postoperative (P = .03 and .01, respectively). CONCLUSIONS The use of ibuprofen plus propacetamol immediately following laparoscopic hernia repair surgery in children resulted in the reduced use of an opioid drug compared with the use of propacetamol alone.
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Affiliation(s)
- Hye-Mi Lee
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hoon Park
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Su-Jung Park
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Haegi Choi
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Rim Lee
- From the Department of Anesthesiology and Pain Medicine.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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12
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Kelley-Quon LI, Kirkpatrick MG, Kim E. Concerns About Pediatric Opioid Prescribing Guidelines-Reply. JAMA Surg 2021; 156:892-893. [PMID: 34076683 DOI: 10.1001/jamasurg.2021.2087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California.,Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles.,Department of Preventive Medicine, University of Southern California, Los Angeles
| | | | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
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13
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Ward A, Jani T, De Souza E, Scheinker D, Bambos N, Anderson TA. Prediction of Prolonged Opioid Use After Surgery in Adolescents: Insights From Machine Learning. Anesth Analg 2021; 133:304-313. [PMID: 33939656 DOI: 10.1213/ane.0000000000005527] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Long-term opioid use has negative health care consequences. Patients who undergo surgery are at risk for prolonged opioid use after surgery (POUS). While risk factors have been previously identified, no methods currently exist to determine higher-risk patients. We assessed the ability of a variety of machine-learning algorithms to predict adolescents at risk of POUS and to identify factors associated with this risk. METHODS A retrospective cohort study was conducted using a national insurance claims database of adolescents aged 12-21 years who underwent 1 of 1297 surgeries, with general anesthesia, from January 1, 2011 to December 30, 2017. Logistic regression with an L2 penalty and with a logistic regression with an L1 lasso (Lasso) penalty, random forests, gradient boosting machines, and extreme gradient boosted models were trained using patient and provider characteristics to predict POUS (≥1 opioid prescription fill within 90-180 days after surgery) risk. Predictive capabilities were assessed using the area under the receiver-operating characteristic curve (AUC)/C-statistic, mean average precision (MAP); individual decision thresholds were compared using sensitivity, specificity, Youden Index, F1 score, and number needed to evaluate. The variables most strongly associated with POUS risk were identified using permutation importance. RESULTS Of 186,493 eligible patient surgical visits, 8410 (4.51%) had POUS. The top-performing algorithm achieved an overall AUC of 0.711 (95% confidence interval [CI], 0.699-0.723) and significantly higher AUCs for certain surgeries (eg, 0.823 for spinal fusion surgery and 0.812 for dental surgery). The variables with the strongest association with POUS were the days' supply of opioids and oral morphine milligram equivalents of opioids in the year before surgery. CONCLUSIONS Machine-learning models to predict POUS risk among adolescents show modest to strong results for different surgeries and reveal variables associated with higher risk. These results may inform health care system-specific identification of patients at higher risk for POUS and drive development of preventative measures.
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Affiliation(s)
- Andrew Ward
- From the Department of Electrical Engineering, Stanford University, Stanford, California
| | - Trisha Jani
- Department of Electrical and Computer Engineering, University of Southern California, Los Angeles, California
| | - Elizabeth De Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - David Scheinker
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Nicholas Bambos
- From the Department of Electrical Engineering, Stanford University, Stanford, California.,Department of Management Science and Engineering, Stanford University, Stanford, California
| | - T Anthony Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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14
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Zhong H, Ladenhauf HN, Wilson LA, Liu J, DelPizzo KR, Poeran J, Memtsoudis SG. Persistent opioid use after surgical treatment of paediatric fracture. Br J Anaesth 2021; 126:1192-1199. [PMID: 33640119 DOI: 10.1016/j.bja.2020.12.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The opioid epidemic is one of the most pressing public health crises in the USA. With fractures being amongst the most common reasons for a child to require surgical intervention and receive post-surgical pain management, characterisation of opioid prescription patterns and risk factors is critical. We hypothesised that the numbers of paediatric patients receiving opioids, or who developed persistent opioid use, are significant, and a number of risk factors for persistent opioid use could be identified. METHODS We conducted a retrospective population-based cohort study. National claims data from the Truven Health Analytics® MarketScan database were used to (i) characterise opioid prescription patterns and (ii) describe the epidemiology and risk factors for single use and persistent use of opioids amongst paediatric patients who underwent surgical intervention for fracture treatment. RESULTS Amongst 303 335 patients, 21.5% received at least one opioid prescription within 6 months after surgery, and 1671 (0.6%) developed persistent opioid use. Risk factors for persistent opioid use include older age; female sex; lower extremity trauma; surgeries involving the spine, rib cage, or head; closed fracture treatment; earlier surgery years; previous use of opioid; and higher comorbidity burden. CONCLUSIONS Amongst a cohort of paediatric patients who underwent surgical fracture treatment, 21.5% filled at least one opioid prescription, and 0.6% (N=1671) filled at least one more opioid prescription between 3 and 6 months after surgery. Understanding risk factors related to persistent opioid use can help clinicians devise strategies to counter the development of persistent opioid use for paediatric patients.
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MESH Headings
- Adolescent
- Age Factors
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Child
- Child, Preschool
- Databases, Factual
- Drug Administration Schedule
- Drug Prescriptions
- Drug Utilization
- Female
- Fracture Fixation/adverse effects
- Fractures, Bone/surgery
- Humans
- Infant
- Infant, Newborn
- Male
- Pain, Postoperative/diagnosis
- Pain, Postoperative/etiology
- Pain, Postoperative/prevention & control
- Practice Patterns, Physicians'
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Time Factors
- Treatment Outcome
- United States
- Young Adult
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Affiliation(s)
- Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Hannah N Ladenhauf
- Department of Paediatric and Adolescent Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Kathryn R DelPizzo
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA.
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