Race and unequal burden of perioperative pain and opioid related adverse effects in children

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

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.

Are There Racial Disparities in Perioperative Pain? A Retrospective Study of a Gynecological Surgery Cohort

PURPOSE

The purpose of this study was to examine whether racial disparities exist in immediate postoperative pain scores and intraoperative analgesic regimens in a single surgical cohort.

DESIGN

A single-center, retrospective analysis.

METHODS

This retrospective study of a single surgical cohort was conducted via chart review of the existing electronic health record. A total of 203 patients who underwent minimally invasive hysterectomy were included in the analysis. Three initially reviewed patient records were excluded from the final analysis due to the small size of their racial cohorts (two Asian or Pacific Islander and one Native American). The White patients (n = 103) and Black patients (n = 100) were compared for differences in pain scores in the postanesthesia care unit (PACU). The patients' intraoperative analgesic regimens were also compared.

FINDINGS

There were no significant differences between races in the postoperative pain scores in the PACU or in the analgesia administered by the anesthesia provider intraoperatively.

CONCLUSIONS

In this specific population, there was no evidence of racial disparities in postoperative pain or intraoperative analgesia administration. Further research is needed to understand the unique factors of the perioperative period, to see if the absence of disparities in this study is repeated in other cohorts, and to mitigate any disparities that are found.

Disparities in Pain Management

Health disparities in pain management remain a pervasive public health crisis. Racial and ethnic disparities have been identified in all aspects of pain management from acute, chronic, pediatric, obstetric, and advanced pain procedures. Disparities in pain management are not limited to race and ethnicity, and have been identified in multiple other vulnerable populations. This review targets health care disparities in the management of pain, focusing on steps health care providers and organizations can take to promote health care equity. A multifaceted plan of action with a focus on research, advocacy, policy changes, structural changes, and targeted interventions is recommended.

Racial Inequity in Pediatric Anesthesia

Purpose of Review

Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism.

Recent Findings

Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments.

Summary

Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.

Postdischarge Nausea and Vomiting and Co-occurring Symptoms in Women Following Breast Cancer Surgery

PURPOSE

The purpose of this study was to investigate the influence of potential co-occurring symptoms, including fatigue, sleep disturbance, anxiety, depressive symptoms, and pain, on the incidence of postdischarge nausea (PDN) measured two days following discharge to home after surgery for breast cancer.

DESIGN

This study used a prospective, cross-sectional, observational design.

METHODS

The sample was 334 women aged 27 to 88 years of age. Demographic data were collected from the patient and the medical record before surgery. Symptom data were collected 48 hours following surgery using the Patient Reported Outcome Measurement System (PROMIS) and numerical nausea and pain scales.

FINDINGS

Eighty-five (25.4%) of study participants reported some nausea two days after discharge. Study participants who experienced PDN frequently described that it occurred after they left the hospital to drive home following their surgery. Unadjusted odds ratios showed the presence of co-occurring symptoms of anxiety, fatigue, sleep disturbance, and pain were all significantly associated with the presence of nausea 48 hours following surgery. Other significant factors associated with (PDN) were history of motion sickness, history of pregnancy-induced nausea, use of opioids, and type of surgery.

CONCLUSIONS

Same-day surgery nurses providing postoperative education for women following surgery for breast cancer should explain to patients that nausea may occur after they are discharged, especially those with known motion sickness. In addition, patients should be informed that other symptoms, especially fatigue, sleep disturbance, and anxiety, may co-occur.

Perioperative pain disparity in children: A call for action

Racial and ethnic disparities in both healthcare management and delivery have been extensively documented in medical literature. For example, patients from non-White minority backgrounds in the United States have been found to experience worse clinical outcomes after surgery, to receive fewer surgical procedures, and to experience worse perioperative pain management compared with patients from non-minority backgrounds. A recent NIH-ACS Symposium on Surgical Disparities Research has identified an urgent need for research aimed at addressing and understanding these disparities. The present review summarizes existing literature describing perioperative pain disparities in children in the United States, as well as highlights the paucity of research in this domain. Specifically, there is a need for randomized control trials and health services research studying pediatric perioperative pain disparities. A multidisciplinary systems-based approach would help translate findings from scientific research to clinical practice and is a crucial step to ensuring all children of diverse backgrounds receive optimal perioperative care.

Pharmacogenetics and Pain Treatment with a Focus on Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Antidepressants: A Systematic Review

Background: This systematic review summarizes the impact of pharmacogenetics on the effect and safety of non-steroidal anti-inflammatory drugs (NSAIDs) and antidepressants when used for pain treatment. Methods: A systematic literature search was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines regarding the human in vivo efficacy and safety of NSAIDs and antidepressants in pain treatment that take pharmacogenetic parameters into consideration. Studies were collected from PubMed, Scopus, and Web of Science up to the cutoff date 18 October 2021. Results: Twenty-five articles out of the 6547 initially detected publications were identified. Relevant medication–gene interactions were noted for drug safety. Interactions important for pain management were detected for (1) ibuprofen/CYP2C9; (2) celecoxib/CYP2C9; (3) piroxicam/CYP2C8, CYP2C9; (4) diclofenac/CYP2C9, UGT2B7, CYP2C8, ABCC2; (5) meloxicam/CYP2C9; (6) aspirin/CYP2C9, SLCO1B1, and CHST2; (7) amitriptyline/CYP2D6 and CYP2C19; (8) imipramine/CYP2C19; (9) nortriptyline/CYP2C19, CYP2D6, ABCB1; and (10) escitalopram/HTR2C, CYP2C19, and CYP1A2. Conclusions: Overall, a lack of well powered human in vivo studies assessing the pharmacogenetics in pain patients treated with NSAIDs or antidepressants is noted. Studies indicate a higher risk for partly severe side effects for the CYP2C9 poor metabolizers and NSAIDs. Further in vivo studies are needed to consolidate the relevant polymorphisms in NSAID safety as well as in the efficacy of NSAIDs and antidepressants in pain management.

Differences in the association between kappa opioid receptors and pain among Black and White adults with alcohol use disorders

BACKGROUND

The relationship between alcohol and pain is complex. Associations between pain and alcohol use disorder (AUD) vary by race, but the underlying biological basis is not understood. We examined the association of the kappa opioid receptor (KOR) with responses to the cold-pressor test (CPT), before and after treatment with the opioid antagonist naltrexone, among individuals with AUD who self-identified as Black or White.

METHODS

Thirty-seven individuals (12 Black, 24 White, and 1 Multiracial) with AUD participated in two CPTs, separated by 1 week during which they received naltrexone 100 mg daily. During each CPT, pain reporting threshold (PRT), average pain increase rate (APIR), relative pain recovery (RPR), and alcohol craving were recorded. KOR availability was measured using [¹¹ C]-LY2795050 positron emission tomography (PET) prior to treatment with naltrexone.

RESULTS

Black participants reported higher PRT and APIR than White participants during the CPT before, but not after, naltrexone treatment. Among Black participants, KOR availability was positively associated with PRT and APIR before, but not after naltrexone. Greater KOR availability was associated with faster RPR for White, but not Black, participants. The CPT induced more alcohol craving in Black than White participants, particularly in individuals with low KOR availability, an effect that was not attenuated by naltrexone.

CONCLUSIONS

KOR involvement and naltrexone effects on responses to the CPT were different between Black and White participants. These preliminary findings suggest that further exploration of the differences in the opioid system and pain among Black and White individuals with AUD and their relationship with naltrexone's effects is warranted.

Association of Race and Ethnicity with Pediatric Postoperative Pain Outcomes

INTRODUCTION

Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes.

METHODS

Medical records of children 0 to ≤ 18 years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference).

PRIMARY OUTCOME

post-anesthesia care unit mean pain score.

SECONDARY OUTCOMES

inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates.

RESULTS

Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score.

CONCLUSIONS

Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.

Impact of Parental Primary Spoken Language on Postoperative Pain Management in Children, a Retrospective Cohort Study

Background: Healthcare providers encounter varying languages every day in patient care. The goal of this study was to examine whether a difference exists in pain scoring and treatment amongst pediatric patients whose families’ primary language was not English. We hypothesized that patients of both Arabic-speaking (AS) and Spanish-speaking (SS) backgrounds received higher pain scores and higher daily opioid equivalents (OEs) postoperatively compared to English-speaking (ES) patients. Methods: This was a retrospective cohort study of patients undergoing surgery for treatment of various esophageal and airway disorders from 2014 to 2019. Records were queried for patients undergoing thoracotomies for treatment of esophageal and airway disorders. Analysis was focused on the three most common languages in this selected population: English, Arabic, and Spanish. Propensity score matching was utilized for comparisons of pain scores between AS, SS, and ES patient groups. Primary outcomes were opioid equivalents (OEs) and pain scores postoperatively. Multivariable median regression analysis was used to perform an adjusted comparison of pain scores as well as OEs. Results: A total of 610 patient encounters were included in our analysis. In propensity matched analysis, there were no significant differences in OEs between all groups postoperatively. However, statistically significant higher pain scores were reported in the ES group matched AS groups. Conclusions: Language differences did not lead to difference in pain assessment and treatment.

Race/Ethnicity and Duration of Anesthesia for Pediatric Patients in the US: a Retrospective Cohort Study

BACKGROUND

Previous literature has demonstrated adverse patient outcomes associated with racial/ethnic disparities in health services. Because patients/parents and providers care about the duration of anesthesia, this study focuses on this outcome.

OBJECTIVES

To determine the association between race/ethnicity and duration under anesthesia.

RESEARCH DESIGN

In this retrospective cohort study of data from the Multicenter Perioperative Outcomes Group, White non-Latino was the reference and was compared with Black non-Latino children, Latino, Asian, Native American, Other, and "Unknown" race children.

SUBJECTS

Children aged 3 to 17 years.

OUTCOMES

Induction duration (primary outcome), procedure-end duration, and total duration under anesthesia (secondary outcomes).

RESULTS

Of 37,596 eligible cases, 9,610 cases with complete data were analyzed. The sample consisted of 6,894 White non-Latino patients, 1,021 Black non-Latino patients, 50 Latino patients, 287 Asian patients, 26 Native American patients, 57 "Other" race patients, and 1,275 patients of "Unknown" race. The mean induction time was 11.9 min (SD 5.6 min). In adjusted analysis, Black non-Latino patients had 5% longer induction and procedure-end durations than White non-Latino children (exponentiated beta coefficient [Exp (β)] 1.05, 95% CI: 1.02-1.08, p < 0.01 and Exp (β) 1.08, 95% CI 1.04-1.13, p < 0.01 respectively).

CONCLUSIONS

White non-Latino children had shorter induction and procedure-end durations than Black children. The differences in induction and procedure-end time were small but may be meaningful on a population-health level.

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.

Opioid Use Disorder and Racial/Ethnic Health Disparities: Prevention and Management

PURPOSE OF REVIEW

This review aims to summarize risks and disparities associated with the prevalence and treatment of opioid use disorder in the perioperative and long-term setting, as well as evidence-based treatment and prevention targeted toward specific vulnerable populations.

RECENT FINDING

There are significant demographic disparities in pain management and development and management of OUD in the chronic and surgical setting. While White patients traditionally receive more pain management, they are also at higher risk of developing OUD. Hispanic and Latin populations have the largest proportion of youth with OUD and often lack culturally appropriate translation services that allow for effective treatment. Native Americans have the second highest rate of OUD and often receive care in communities and healthcare settings that lack funding and resources to combat OUD. African Americans tend to suffer from the criminalization of OUD and are less able to seek treatment due to this, and furthermore, often lack community services that would benefit them. Additional vulnerable populations include homeless individuals that lack access to healthcare or health insurance. In addition, incarcerated individuals often lack access to naloxone and suffer from high rates of fatal overdose soon after being released to the community. People in rural settings lack needle-exchange programs and community-based interventions/support groups. Patients in the perioperative setting lack standard screening and pain management protocols. Interventions targeted toward each appropriate group can help decrease the rate of OUD and improve its treatment, and overarching interventions such as protocols, targeted funding, education and regulation can combat OUD for all populations.

Perioperative Pain Management Practices Vary Across Time and Setting for Pediatric ACL Reconstruction: Trends From a National Database in the United States

Background:

Surgical and anesthetic techniques have enabled a shift to the ambulatory setting for the majority of patients with anterior cruciate ligament (ACL) tears. While this change likely reflects improvements in acute pain management, little is known about national trends in pediatric perioperative pain management after ACL reconstruction (ACLR).

Purpose:

To describe recent trends in the United States in perioperative pain management for pediatric ACLR.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Pediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve blocks between January 2008 and December 2017 were identified in the Pediatric Health Information System database. We modeled the use of oral and intravenous analgesic medications over time using Bayesian logistic mixed models. Models were adjusted for patient age, sex, race, primary payer, and treatment setting (ambulatory, observation, or inpatient).

Results:

The study criteria produced a sample of 18,605 patients. Older children were more likely to receive intravenous acetaminophen, intravenous ketorolac, and oral and intravenous opioids. Younger children were more likely to receive ibuprofen. In our adjusted logistic model, treatment setting was found to be an independent predictor of the utilization of all medications. We found an increase in the overall utilization of oral acetaminophen (adjusted odds ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI, 1.06-1.28]) over the study period at a typical hospital. We found significant heterogeneity in medication use across hospitals, with the most heterogeneity in intravenous acetaminophen. Other studied descriptive variables did not appear to predict practices.

Conclusion:

After adjusting for patient characteristics and treatment settings, pain management strategies varied among hospitals and over time. Patient age and treatment setting predicted practices. Regional anesthesia, opioid medications, and intravenous ketorolac remained the mainstays of treatment, while intravenous acetaminophen emerged in use over the course of the study period. The variability in the pain management of pediatric patients undergoing ACLR suggests that further study is necessary to establish the most effective means of perioperative pain management in these patients.

Use of Opioids and Nonopioid Analgesics to Treat Pediatric Postoperative Pain in the Emergency Department

OBJECTIVES

The incidence, demographic characteristics, and treatment approaches for pediatric patients who present to the ED with a primary complaint of postoperative pain have not been well described. The purpose of this study was to describe opioid and nonopioid prescribing patterns for pediatric patients evaluated for postoperative pain in the Emergency Department (ED).

METHODS

Pediatric Health Information System is an administrative database of encounter-level data from 48 children's hospitals. Emergency department visits for postoperative pain from January 2014 to September 2017 were analyzed. Visits were matched by the Pediatric Health Information System identifier to associate corresponding same site surgery encounters directly preceding ED visits.

RESULTS

There were 7365 ED visits for acute postoperative pain, for which 4044 could be linked to corresponding surgical procedure. Eight-one percent of ED visits were within 7 days of surgery. Opioids were given at 1979 (49%) of visits, and nonopioids at 678 (17%) of visits. The most common surgeries preceding a postoperative pain ED visit were for tonsils and adenoids (48.5%). Age, sex, length of stay for both procedure and ED visits, procedure specialty, and the number of days between procedure discharge and admission to ED were associated with opioid administration during ED visits (P < 0.05).

CONCLUSIONS

Pediatric patients treated in the ED for postoperative pain were often treated with opioid and nonopioid analgesics, with wide prescriber variability. Further research is warranted to help balance optimal pain management and safe prescribing practices.

Examining adolescents' opioid knowledge and likelihood to Utilize an educational game to promote medication safety

BACKGROUND

Adolescents' knowledge on opioids is seldom studied, despite the fact young people are one of the groups most affected by the opioid crisis within the United States. There is a need to understand adolescents' perceptions about opioid misuse and safety to create the necessary tools to educate adolescents on safe opioid use.

OBJECTIVE

This study sought to understand adolescents' knowledge and perceptions of opioid use and safety as well as their receptiveness to using an educational game for improving medication safety knowledge.

METHODS

A 67-item survey was developed to assess adolescents' opioid perceptions, knowledge, and the likelihood of an educational game to enhance their opioid medication safety. A nationally representative sample of US adolescents aged 12 to 18 were recruited via a Qualtrics participant panel to complete the online survey from October through November 2020. Survey questions were grouped into 10 categories to represent key concepts and summarized into concept scores. Concepts were described through means, median, and range as well as percent correct for individual questions. Differences between groups were assessed using Kruskal-Wallis tests. Concept scores and their relation to the participant's age were described by the Pearson's correlation coefficient and the linear model coefficient.

RESULTS

A total of 592 responses were analyzed. Male and older participants reported greater perceived opioid knowledge than females. White participants reported higher rates of perceived opioid knowledge, behavioral intent, and knowledge of safe medication disposal than any other racial group. About 80% of participants were receptive to the use of an educational game to increase their opioid safety knowledge.

CONCLUSIONS

There are discrepancies in adolescents' knowledge on opioid safety and harm amongst genders, race, and age. Study findings support the use of an educational game to increase adolescents' opioid knowledge. Future studies should design an educational game intended for a diverse audience.

An assessment of opioids on respiratory depression in children with and without obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea is a risk factor for respiratory depression following opioid administration as well as opioid-induced hyperalgesia. Little is known on how obstructive sleep apnea status is associated with central ventilatory depression in pediatric surgical patients given a single dose of fentanyl.

METHODS

This was a single-center, prospective trial in children undergoing surgery requiring intubation and opioid administration. Sixty patients between the ages of 2-8 years presenting for surgery at Texas Children's Hospital were recruited. Twenty non-obstructive sleep apnea controls and 30 patients with moderate to severe obstructive sleep apnea met inclusion criteria. Following induction of general anesthesia and establishment of steady-state ventilation, participants received 1 mcg/kg intravenous fentanyl. Ventilatory variables (tidal volume, respiratory rate, end-tidal CO₂ , and minute ventilation) were assessed each minute for 10 min. The primary outcome was the extent of opioid-induced central ventilatory depression over time by obstructive sleep apnea status when compared with baseline values. Secondary aims assessed the impact of demographics and SpO₂ nadir on ventilatory depression.

RESULTS

We found no significant difference in percent decrease in respiratory rate (38.1% and 37.1%; p = .950), tidal volume (6.4% and 5.4%; p = .992), and minute ventilation (35.0 L/min and 35.0 L/min; p = .890) in control and obstructive sleep apnea patients, respectively. Both groups experienced similar percent increases in end-tidal CO₂ (4.0% vs. 2.2%; p = .512) in control and obstructive sleep apnea patients, respectively.

CONCLUSIONS

In pediatric surgical patients, obstructive sleep apnea status was not associated with significant differences in central respiratory depression following a single dose of fentanyl (1 mcg/kg). These findings can help determine safe opioid doses in future pediatric obstructive sleep apneapatients.

Model-Informed Bayesian Estimation Improves the Prediction of Morphine Exposure in Neonates and Infants

BACKGROUND

Pain control in infants is an important clinical concern, with potential long-term adverse neurodevelopmental effects. Intravenous morphine is routinely administered for postoperative pain management; however, its dose-concentration-response relationship in neonates and infants has not been well characterized. Although the current literature provides dosing guidelines for the average infant, it fails to control for the large unexplained variability in morphine clearance and response in individual patients. Bayesian estimation can be used to control for some of this variability. The authors aimed to evaluate morphine pharmacokinetics (PKs) and exposure in critically ill neonates and infants receiving standard-of-care morphine therapy and compare a population-based approach to the model-informed Bayesian techniques.

METHODS

The PKs and exposure of morphine and its active metabolites were evaluated in a prospective opportunistic PK study using 221 discarded blood samples from 57 critically ill neonates and infants in the neonatal intensive care unit. Thereafter, a population-based PK model was compared with a Bayesian adaptive control strategy to predict an individual's PK profile and morphine exposure over time.

RESULTS

Among the critically ill neonates and infants, morphine clearance showed substantial variability with a 40-fold range (ie, 2.2 to 87.1, mean 23.7 L/h/70 kg). Compared with the observed morphine concentrations, the population-model based predictions had an R of 0.13, whereas the model-based Bayesian predictions had an R of 0.61.

CONCLUSIONS

Model-informed Bayesian estimation is a better predictor of morphine exposure than PK models alone in critically ill neonates and infants. A large variability was also identified in morphine clearance. A further study is warranted to elucidate the predictive covariates and precision dosing strategies that use morphine concentration and pain scores as feedbacks.

Association of Race and Ethnicity with Sedation Management in Pediatric Intensive Care

Rationale: Racial disparities in pain management have been previously reported for children receiving emergency care.Objectives: To determine whether patient race or ethnicity is associated with the broader goal of pain management and sedation among pediatric patients mechanically ventilated for acute respiratory failure.Methods: Planned secondary analysis of RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure). RESTORE, a cluster-randomized clinical trial conducted in 31 U.S. pediatric intensive care units, compared protocolized sedation management (intervention arm) with usual care (control arm). Participants included 2,271 children identified as non-Hispanic white (white, n = 1,233), non-Hispanic Black (Black, n = 502), or Hispanic of any race (Hispanic, n = 536).Results: Within each treatment arm, neither opioid nor benzodiazepine selection, nor cumulative dosing, differed significantly among race and ethnicity groups. Black patients experienced fewer days with an episode of pain (compared with white patients in the control arm and with Hispanic patients in the intervention arm) and experienced less iatrogenic withdrawal syndrome (compared with white patients in either arm or with Hispanic patients in the intervention arm). The percentage of days awake and calm while intubated was not significantly different in pairwise comparisons by race and ethnicity groups in either the control arm (median: white, 75%; Black, 71%; Hispanic, 75%) or the intervention arm (white, 86%; Black, 88%; Hispanic, 85%).Conclusions: Across multiple measures, our study found scattered differences in sedation management among critically ill Black, Hispanic, and white children that did not consistently favor any group. However, racial disparities related to implicit bias cannot be completely ruled out.Clinical trial registered with clinicaltrials.gov (NCT00814099).

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Treatment recommendations to parents during pediatric tonsillectomy consultations: A mixed methods analysis of surgeon language

OBJECTIVE

A deeper understanding of the dialogue clinicians use to relay treatment recommendations is needed to fully understand their influence on patient decisions about surgery. We characterize how otolaryngologists provide treatment recommendations and suggest a classification framework.

METHODS

We qualitatively analyzed surgeon recommendations from 55 encounters between otolaryngologists and parents of children evaluated for tonsillectomy, and classified recommendation types by phrasing. Multilevel logistic regression identified predictors of recommendation phrasing.

RESULTS

Clinicians provided 183 recommendations (mean/visit = 3.3). We identified four domains of recommendation-phrasing (direct, passive, acceptable, parent-oriented). Direct recommendations (n = 68, 37%) included presumptive statements phrasing intentions as inevitable. Passive recommendations (n = 65, 36%) included practice-based recommendations utilizing general statements. Acceptable recommendations (n = 29, 16%) included speaking positively about treatment options. Parent-oriented recommendations (n = 21, 11%) included parent choice statements. Clinicians more commonly made direct recommendations to parents who were racial minorities (OR = 2.7, p = .02, 95% CI [1.7, 5.9]) or had an annual income <$50,000 (OR = 2.2, p = .03, 95% CI [1.1, 4.4]).

CONCLUSION

Clinicians provide treatment recommendations in a variety of ways that may introduce more or less certainty and choice to parental treatment decisions.

PRACTICE IMPLICATIONS

Findings may be implemented into training which increases clinician awareness of dialogue use when recommending treatment alternatives to patients.

Perioperative Opioid Consumption is Not Reduced in Cyanotic Patients Presenting for the Fontan Procedure

Adequate pain control is a critical component of the perioperative approach to children undergoing repair of congenital heart disease (CHD). The impact of specific anatomic and physiologic disturbances on the management of analgesia has been largely unexplored at the present time. Studies in other pediatric populations have found an association between chronic hypoxemia and an increased sensitivity to the effects of opioid medications. The purpose of this retrospective study was to examine perioperative opioid administration and opioid-associated adverse effects in children undergoing surgical repair of CHD, with a comparison between patients with and without chronic preoperative cyanosis. Patients between the ages of 2 and 5 years whose tracheas were extubated in the operating room were included and were classified in the cyanotic group if they presented for the Fontan completion. The primary outcomes of interest were intraoperative and postoperative opioid administration. Secondary outcomes included pain scores and opioid-related side effects. The study cohort included 156 patients. Seventy-one underwent the Fontan procedure, twelve of which were fenestrated. Fontan patients received fewer opioids intraoperatively (11.33 µg/kg fentanyl equivalents versus 12.56 µg/kg, p = 0.03). However, there were no differences with regards to opioid consumption postoperatively and no correlation between preoperative oxygen saturation and total opioid administration. There were no differences between groups with regards to the respiratory rate nadir, postoperative pain scores, or the incidence of opioid-related side effects. In contrast to other populations with chronic hypoxemia exposure, children with cyanotic CHD did not appear to have increased sensitivity to the effects of opioid medications.

Quantitative Pupillometry as a Predictor of Pediatric Postoperative Opioid-Induced Respiratory Depression

BACKGROUND

Safe postoperative pain relief with opioids is an unmet critical medical need in children. There is a lack of objective, noninvasive bedside tool to assess central nervous system (CNS) effects of intraoperative opioids. Proactive identification of children at risk for postoperative respiratory depression (RD) will help tailor analgesic therapy and significantly improve the safety of opioids in children. Quantitative pupillometry (QP) is a noninvasive, objective, and real-time tool for monitoring CNS effect-time relationship of opioids. This exploratory study aimed to determine the association of QP measures with postoperative RD, as well as to identify the best intraoperative QP measures predictive of postoperative RD in children.

METHODS

After approval from the institutional review board and informed parental consent, in this prospective, observational study of 220 children undergoing tonsillectomy, QP measures were collected at 5 time points: awake preoperative baseline before anesthesia induction (at the time of enrollment [T1]), immediately after anesthesia induction before morphine administration (T2), 3 minutes after intraoperative morphine administration (T3), at the end of surgery (T4), and postoperatively when awake in postanesthesia recovery unit (PACU) (T5). Intraoperative use of opioid and incidence of postoperative RD were collected. Analyses were aimed at exploring correlations of QP measures with the incidence of RD and, if found significant, to develop a predictive model for postoperative RD.

RESULTS

Perioperative QP measures of percentage pupil constriction (CONQ, P = .027), minimum pupillary diameter (MIN, P = .027), and maximum pupillary diameter (MAX, P = .034) differed significantly among children with and without postoperative RD. A predictive model including the minimum pupillary diameter 3 minutes after morphine administration (MIN3), minimum pupillary diameter normalized to baseline (MIN31), and percentage pupillary constriction after surgery (T4) standardized to baseline (T1) (CONQ41), along with the weight-based morphine dose performed the best to predict postoperative RD in children (area under the curve [AUC], 0.76).

CONCLUSIONS

A model based on pre- and intraoperative pupillometry measures including CONQ, MIN, along with weight-based morphine dose-predicted postoperative RD in our cohort of children undergoing tonsillectomy. More studies with a larger sample size are required to validate this finding.

The Influence of the Opioid Epidemic on Firearm Violence in Kentucky Counties

BACKGROUND

The opioid crisis is a major public health emergency. Current data likely underestimate the full impact on mortality due to limitations in reporting and toxicology screening. We explored the relationship between opioid overdose and firearm-associated emergency department visits (ODED & FAED, respectively).

METHODS

For the years 2010 to 2017, we analyzed county-level ODED and FAED visits in Kentucky using Office of Health Policy and US Census Bureau data. Firearm death certificate data were analyzed along with high-dose prescriptions from the Kentucky All Schedule Prescription Electronic Reporting records. Socioeconomic variables analyzed included health insurance coverage, race, median household earnings, unemployment rate, and high-school graduation rate.

RESULTS

ODED and FAED visits were correlated (Rho = 0.29, P< 0.01) and both increased over the study period, remarkably so after 2013 (P < 0.001). FAED visits were higher in rural compared to metro counties (P < 0.001), while ODED visits were not. In multivariable analysis, FAED visits were associated with ODED visits (Std. B = 0.24, P= 0.001), high-dose prescriptions (0.21, P = 0.008), rural status (0.19, P = 0.012), percentage white race (-0.28, P = 0.012), and percentage high school graduates (-0.68, P < 0.001). Unemployment and earnings were bivariate correlates with FAED visits (Rho = 0.42, P < 0.001 and -0.32, P < 0.001, respectively) but were not significant in the multivariable model.

CONCLUSIONS

In addition to recognized nonfatal consequences of the opioid crisis, firearm violence appears to be a corollary impact, particularly in rural counties. Firearm injury prevention efforts should consider the contribution of opioid use and abuse.

Effects of the FDA Codeine Safety Investigation on Racial and Geographic Disparities in Opioid Prescribing after Pediatric Tonsillectomy and/or Adenoidectomy

Objective. Our objective was to examine the impact of the U.S. FDA’s 2013 black box warning against codeine on codeine and other opioid prescription filling after pediatric tonsillectomy and/or adenoidectomy (T/A) overall and by child race and provider urbanity/rurality. Methods. Patients ≤ 18 who underwent T/A in 8/2011 to 8/2016 were identified in Ohio Medicaid claims. Interrupted time series analyses were used to evaluate the impact of the FDA warning on codeine or other opioid prescription filling post-T/A. Results. In August 2011, codeine prescription filling was lower among black than white children (P < .001) and among children treated at institutions in metropolitan counties than less populous counties (P < .001). The FDA warning was associated with a 24.0% drop in codeine prescription filling (P < .001) and 5.5% increase in alternative opioid prescription filling (P = .046). At conclusion, there remained geographic but no longer racial disparities in codeine prescribing. Conclusion. Codeine prescribing after pediatric T/A decreased after the FDA’s black box warning. However, geographic disparities in codeine prescribing remain.

The Association of Dexmedetomidine on Perioperative Opioid Consumption in Children Undergoing Adenotonsillectomy With and Without Obstructive Sleep Apnea

BACKGROUND

Dexmedetomidine is used to reduce opioid consumption in pediatric anesthesia. However, there is conflicting evidence in pediatric adenotonsillectomy literature regarding the total perioperative opioid-sparing effects of dexmedetomidine. The aim of this study was to examine the association between dexmedetomidine and total perioperative opioid consumption in children undergoing adenotonsillectomy.

METHODS

This was a retrospective cohort study of the children undergoing adenotonsillectomy surgery at Texas Children's Hospital between November 2017 and October 2018. Intraoperative dexmedetomidine was the exposure of interest. The primary outcome was total perioperative opioid consumption calculated as oral morphine equivalents (OME). Secondary outcomes of interest included opioid consumption and pain scores based on presence and absence of obstructive sleep apnea (OSA) and postanesthesia care unit (PACU) duration. We used multivariable linear regression to estimate the association of dexmedetomidine on the outcomes.

RESULTS

A total of 941 patients met inclusion criteria, 697 (74.1%) received intraoperative dexmedetomidine. For every 0.1 µg/kg increase in intraoperative dexmedetomidine, the total perioperative OME (mg/kg) decreases by 0.021 mg/kg (95% CI, -0.027 to -0.015; P < .001). Pain scores did not significantly vary by OSA status. PACU duration increased by 1.14 minutes (95% CI, 0.30-1.99; P = .008) for each 0.1 µg/kg of intraoperative dexmedetomidine.

CONCLUSIONS

Dexmedetomidine is associated with an overall perioperative opioid-sparing effect in children undergoing adenotonsillectomy and a small but statistically significant increase in PACU duration. Additionally, children with OSA did not have reduced perioperative opioid consumption.

Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist

Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.

Evaluation of racial disparities in postoperative opioid prescription filling after common pediatric surgical procedures

BACKGROUND

Racially disparate pain management affects both adult and pediatric patients, but is not well studied among pediatric surgical patients after discharge. The objectives were to evaluate racial disparities in pediatric postoperative opioid prescription filling.

METHODS

This retrospective cohort study included black or white pediatric Medicaid patients who underwent tonsillectomy, supracondylar humeral fracture fixation, or appendectomy (2/2012-7/2016). Patients were followed for 14 days post-surgery to identify opioid prescription fills. Logistic regression models evaluated the association between race and the probability of filling an opioid prescription.

RESULTS

Among 39,316 surgical patients, the proportions of patients with post-surgical opioid prescriptions were 66.0%, 83.9%, and 68.5%, among tonsillectomy, supracondylar fracture, and appendectomy patients, respectively. The proportion of black appendectomy patients with a postoperative opioid prescription was significantly lower compared to white patients (65.0% vs. 69.2% respectively, p = 0.03), but was no longer significant after adjusting for other patient and provider characteristics. There were no differences by race in opioid prescription filling among other surgical patient groups.

CONCLUSIONS

The present study did not identify racial disparities in opioid prescription filling in adjusted analyses. Racial differences in unadjusted postoperative opioid prescription filling among appendectomy patients may be explained in part by longer postoperative length-of-stay among black children.

TYPE OF STUDY

Prognosis Study LEVEL OF EVIDENCE: Level II.

Parent responses to pediatric pain: The differential effects of ethnicity on opioid consumption

OBJECTIVE

Within the context of the United States opioid epidemic, some parents often fear the use of opioids to help manage their children's postoperative pain. As a possible consequence, parents often do not dispense optimal analgesic medications to their children after surgery, putting their children at risk of suffering from postsurgical pain. The objective of this research was to assess ethnicity as a predictor of both pain and opioid consumption, and to examine how Hispanic/Latinx and Non-Hispanic White parents alter their child's opioid consumption in response to significant postsurgical pain.

METHODS

Participants were 254 children undergoing outpatient tonsillectomy and/or adenoidectomy surgery and their parents. Longitudinal multilevel modeling examined changes in both parent-reported pain and hydrocodone/APAP consumption (mg/kg) on days 1 to 7 after surgery.

RESULTS

Parent reports of postoperative pain were higher in Hispanic/Latinx patients compared to their Non-Hispanic White counterparts (β = -0.15; 95% CI: -0.28, -0.01). There was also a significant interaction of ethnicity and pain on opioid consumption (β = 0.07; 95% CI: 0.01, 0.13). The relationship between parent perceived pain and opioid use was stronger for Non-Hispanic White children, suggesting that this group was more likely to consume opioids to help manage clinically significant postsurgical pain.

CONCLUSIONS

Hispanic/Latinx children might be at risk for undertreatment of surgical pain. Findings highlight the importance of assessing parent background and cultural beliefs as predictors of at home pain management and the potential effectiveness of tailored interventions that educate parents about monitoring and treating child postoperative pain.

Opioid Prescribing Patterns Following Pediatric Tonsillectomy in the United States, 2009-2017

OBJECTIVES

Assess national trends in opioid prescription following pediatric tonsillectomy: 1) overall percentage receiving opioids and mean quantity, 2) changes during 2009-2017, and 3) determinants of prescription patterns.

METHODS

Cross-sectional analysis using 2009-2017 Optum claims data to identify opioid-naïve children aged 1-18 with claims codes for tonsillectomy (n = 82,842). Quantities of opioids filled in outpatient pharmacies during the perioperative period were extracted and converted into milligram morphine equivalents (MMEs) for statistical comparison. Demographic, clinical, and socioeconomic predictors of opioid fill rate and quantity were determined using regression analyses.

RESULTS

In 2009, 83.3% of children received opioids, decreasing to 58.3% by 2017. Rates of all-cause readmissions and post-tonsillectomy hemorrhages were similar over time. Mean quantity received was 153.47MME (95% confidence intervals [95%CI]: 151.19, 155.76) and did not significantly change during 2009-2017. Opioids were more likely in older children and those with higher household income, but less likely in children with obstructive sleep apnea, other comorbidities, and Hispanic race. Higher quantities of opioids were more likely in older children, while lower quantities were associated with female sex, Hispanic race, and higher household income. Outpatient steroids were prescribed to 8.04% of patients, who were less likely to receive opioids.

CONCLUSION

While the percentage of children receiving post-tonsillectomy opioids decreased during 2009-2017, prescribed quantities remain high and have not decreased over time. Prescription practices were also influenced by clinical and sociodemographic factors. These results highlight the need for guidance, particularly with regard to opioid quantity, in children after tonsillectomy.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:E1722-E1729, 2021.

Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy

Race and ethnicity are associated with disparities in pain management in children. While low English language proficiency is correlated with minority race/ethnicity in the United States, it is less frequently explored in the study of health disparities. We therefore investigated whether English language proficiency influenced pain management in the post-anesthesia care unit (PACU) in a cohort of children who underwent laparoscopic appendectomy at our pediatric hospital in San Francisco. Our primary exposure was English language proficiency, and our primary outcome was administration of any opioid medication in the PACU. Secondary outcomes included the amount of opioid administered in the PACU and whether any pain score was recorded during the patient's recovery period. Statistical analysis included adjusting for demographic covariates including race in estimating the effect of language proficiency on these outcomes. In our cohort of 257 pediatric patients, 57 (22.2%) had low English proficiency (LEP). While LEP and English proficient (EP) patients received the same amount of opioid medication intraoperatively, in multivariable analysis, LEP patients had more than double the odds of receiving any opioid in the PACU (OR 2.45, 95% CI 1.22-4.92). LEP patients received more oral morphine equivalents (OME) than EP patients (1.64 OME/kg, CI 0.67-3.84), and they also had almost double the odds of having no pain score recorded during their PACU recovery period (OR 1.93, CI 0.79-4.73), although the precision of these estimates was limited by small sample size. Subgroup analysis showed that children over the age of 5 years, who were presumably more verbal and would therefore undergo verbal pain assessments, had over triple the odds of having no recorded pain score (OR 3.23, CI 1.48-7.06). In summary, English language proficiency may affect the management of children's pain in the perioperative setting. The etiology of this language-related disparity is likely multifactorial and should be investigated further.

Race, Ethnicity, and Insurance: the Association with Opioid Use in a Pediatric Hospital Setting

BACKGROUND

This study examined the association between race/ethnicity and health insurance payer type with pediatric opioid and non-opioid ordering in an inpatient hospital setting.

METHODS

Cross-sectional inpatient encounter data from June 2013 to June 2018 was retrieved from a pediatric children's hospital in Southern California (N = 55,944), and statistical analyses were performed to determine associations with opioid ordering.

RESULTS

There was a significant main effect of race/ethnicity on opioid and non-opioid orders. Physicians ordered significantly fewer opioid medications, but a greater number of non-opioid medications, for non-Hispanic African American children than non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic White pediatric patients. There was also a main effect of health insurance payer type on non-opioid orders. Patients with government-sponsored plans (e.g., Medi-Cal, Medicare) received fewer non-opioid prescriptions compared with patients with both HMO and PPO coverage. Additionally, there was a significant race/ethnicity by insurance interaction on opioid orders. Non-Hispanic White patients with "other" insurance coverage received the greatest number of opioid orders. In non-Hispanic African American patients, children with PPO coverage received fewer opioids than those with government-sponsored and HMO insurance. For non-Hispanic Asian patients, children with PPO were prescribed more opioids than those with government-sponsored and HMO coverage.

CONCLUSION

Findings suggest that the relationship between race/ethnicity, insurance type, and physician decisions opioid prescribing is complex and multifaceted. Given that consistency in opioid prescribing should be seen regardless of patient background characteristics, future studies should continue to assess and monitor unequitable differences in care.

Organic Cation Transporters in Health and Disease

The organic cation transporters (OCTs) OCT1, OCT2, OCT3, novel OCT (OCTN)1, OCTN2, multidrug and toxin exclusion (MATE)1, and MATE kidney-specific 2 are polyspecific transporters exhibiting broadly overlapping substrate selectivities. They transport organic cations, zwitterions, and some uncharged compounds and operate as facilitated diffusion systems and/or antiporters. OCTs are critically involved in intestinal absorption, hepatic uptake, and renal excretion of hydrophilic drugs. They modulate the distribution of endogenous compounds such as thiamine, L-carnitine, and neurotransmitters. Sites of expression and functions of OCTs have important impact on energy metabolism, pharmacokinetics, and toxicity of drugs, and on drug-drug interactions. In this work, an overview about the human OCTs is presented. Functional properties of human OCTs, including identified substrates and inhibitors of the individual transporters, are described. Sites of expression are compiled, and data on regulation of OCTs are presented. In addition, genetic variations of OCTs are listed, and data on their impact on transport, drug treatment, and diseases are reported. Moreover, recent data are summarized that indicate complex drug-drug interaction at OCTs, such as allosteric high-affinity inhibition of transport and substrate dependence of inhibitor efficacies. A hypothesis about the molecular mechanism of polyspecific substrate recognition by OCTs is presented that is based on functional studies and mutagenesis experiments in OCT1 and OCT2. This hypothesis provides a framework to imagine how observed complex drug-drug interactions at OCTs arise. Finally, preclinical in vitro tests that are performed by pharmaceutical companies to identify interaction of novel drugs with OCTs are discussed. Optimized experimental procedures are proposed that allow a gapless detection of inhibitory and transported drugs.

Association Between Race and Ethnicity in the Delivery of Regional Anesthesia for Pediatric Patients: A Single-Center Study of 3189 Regional Anesthetics in 25,664 Surgeries

BACKGROUND

Racial and ethnic disparities in health care are well documented in the United States, although evidence of disparities in pediatric anesthesia is limited. We sought to determine whether there is an association between race and ethnicity and the use of intraoperative regional anesthesia at a single academic children's hospital.

METHODS

We performed a retrospective review of all anesthetics at an academic tertiary children's hospital between May 4, 2014, and May 31, 2018. The primary outcome was delivery of regional anesthesia, defined as a neuraxial or peripheral nerve block. The association between patient race and ethnicity (white non-Hispanic or minority) and receipt of regional anesthesia was assessed using multivariable logistic regression. Sensitivity analyses were performed comparing white non-Hispanic to an expansion of the single minority group to individual racial and ethnic groups and on patients undergoing surgeries most likely to receive regional anesthesia (orthopedic and urology patients).

RESULTS

Of 33,713 patient cases eligible for inclusion, 25,664 met criteria for analysis. Three-thousand one-hundred eighty-nine patients (12.4%) received regional anesthesia. One thousand eighty-six of 8884 (13.3%) white non-Hispanic patients and 2003 of 16,780 (11.9%) minority patients received regional anesthesia. After multivariable adjustment for confounding, race and ethnicity were not found to be significantly associated with receiving intraoperative regional anesthesia (adjusted odds ratios [ORs] = 0.95; 95% confidence interval [CI], 0.86-1.06; P = .36). Sensitivity analyses did not find significant differences between the white non-Hispanic group and individual races and ethnicities, nor did they find significant differences when analyzing only orthopedic and urology patients, despite observing some meaningful clinical differences.

CONCLUSIONS

In an analysis of patients undergoing surgical anesthesia at a single academic children's hospital, race and ethnicity were not significantly associated with the adjusted ORs of receiving intraoperative regional anesthesia. This finding contrasts with much of the existing health care disparities literature and warrants further study with additional datasets to understand the mechanisms involved.

Opioids or Steroids for Pneumonia or Sinusitis

OBJECTIVES

To compare the frequency of opioid and corticosteroid prescriptions dispensed for children with pneumonia or sinusitis visits on the basis of location of care.

METHODS

We evaluated 2016 South Carolina Medicaid claims data for 5 to 18 years olds with pneumonia or sinusitis. Visits were associated with 1 of 3 locations: the emergency department (ED), urgent care, or the ambulatory setting.

RESULTS

Inclusion criteria were met by 31 838 children. Pneumonia visits were more often linked to an opioid prescription in the ED (34 of 542 [6.3%]) than in ambulatory settings (24 of 1590 [1.5%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (106 of 542 [19.6%]) than in ambulatory settings (196 of 1590 [12.3%]; P ≤ .0001). Sinusitis visits were more often linked to an opioid prescription in the ED (202 of 2705 [7.5%]) than in ambulatory settings (568 of 26 866 [2.1%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (510 of 2705 [18.9%]) than in ambulatory settings (1922 of 26 866 [7.2%]; P ≤ .0001). In logistic regression for children with pneumonia, the ED setting was associated with increased odds of receiving an opioid (adjusted odds ratio [aOR] 4.69) or steroid (aOR 1.67). Similarly, patients with sinusitis were more likely to be prescribed opioids (aOR 4.02) or steroids (aOR 3.05) in the ED than in ambulatory sites.

CONCLUSIONS

School-aged children received opioid and steroid prescriptions for pneumonia or sinusitis at a higher frequency in the ED versus the ambulatory setting.

Navigating the Intersection Between Persistent Pain and the Opioid Crisis: Population Health Perspectives for Physical Therapy

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.

Racial and Ethnic Health Services Disparities in Pediatric Anesthesia Practice: A Scoping Review

Racial and ethnic disparities in pediatric anesthesia health services could result in minority children being at increased risk of poor outcomes, such as pain, anxiety, or over-exposure to medications. Yet, a comprehensive understanding of the literature on such disparities does not exist to date. The objective of this study is to describe health services disparities in pediatric anesthetic care in the pre-, intra-, or post-operative period by synthesizing current literature. We searched the National Library of Medicine's PubMed/Medline, Embase, and Web of Science for articles published between January 1, 2007, and May 9, 2020, to identify literature on racial and ethnic health services disparities in pediatric anesthesia. We used the Institute of Medicine's definition of disparities. Health services were related to pre-, intra-, or post-operative anesthetic care of pediatric patients (< 18 years old). Out of 2110 studies, 10 studies met the criteria for inclusion. Nine out of the ten articles were single-institutional observational studies, based at tertiary hospitals. Sample sizes ranged from 74 to 37,618 discrete participants, for a total of 69,350 subjects across all studies. Results of these studies present low-quality evidence and heterogeneous conclusions regarding pediatric anesthesia health services disparities. This review demonstrates the paucity and diversity of research on racial and ethnic disparities in pediatric anesthesia health services and suggests how future work might utilize improved data and rigorous study designs.

Receipt of multiple outpatient opioid prescriptions is associated with increased risk of adverse outcomes in youth: opioid prescribing trends, individual characteristics, and outcomes from 2005 to 2016

Data on all outpatient opioid prescriptions (N = 71,647) to youth below age 21 (N = 42,020) from 2005 to 2016 were extracted from electronic medical records within a university hospital system in New Mexico (NM) as were demographic details and markers of morbidity/mortality. Relative risk was calculated for markers of morbidity/mortality based on sociodemographic characteristics. The sample was primarily male (55.0%), Hispanic/Latinx (50.1%), English-speaking (88.9%), and publicly insured (50.1%). Mean age was 13.54 (SD = 6.50). From 2005 to 2016, overall frequency of opioid prescriptions increased by 86.6% (from 2470 to 4610) with the largest increase (206.2%) observed from 2005 to 2008 (2470-7562). Patients who were older, white, and non-Hispanic were more likely to receive multiple opioid prescriptions. Large relative increases in morbidity and mortality were documented, although base rates remained low. The percentage of individuals within the sample who experienced an overdose increased steadily from 0 in 2005 to 1.09% in 2016. Incidence of mortality increased from 0.12% of the sample to 1.39% in 2016. The proportion of individuals who received a medication for the treatment of opioid dependence increased from 0.06% in 2005 to 0.44% in 2016. Significantly increased risk of adverse outcomes was observed in patients receiving multiple opioid prescriptions, and in patients who were older, of minority race, received their first prescription in an outpatient clinic, and publicly insured or uninsured. Results add to the growing literature concerning opioid prescription rates over time. They also provide important information on potential additive risks of adverse outcomes when pediatric patients receive multiple opioid prescriptions.

Racial Disparities in Pediatric Anesthesia

Racial disparities in health care have been extensively documented. Although race is a recognized determinant of the incidence and outcome of disease, few studies have examined the role of race in the delivery of pediatric perianesthesia care. Whereas racial differences in health outcomes may not be easy to modify, disparities in health care delivery are modifiable. The authors examined literature to determine whether racial disparities exist in the delivery of pediatric anesthesia. They explored putative contributors to disparities at the provider, patient, and systems level and propose ideas to address potential causes of disparities in the practice of pediatric anesthesia.

Racial Differences in Perioperative Opioid Utilization in Lumbar Decompression and Fusion Surgery for Symptomatic Lumbar Stenosis or Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To assess for racial differences in opioid utilization prior to and after lumbar fusion surgery for patients with lumbar stenosis or spondylolisthesis.

METHODS

Clinical records from patients with lumbar stenosis or spondylolisthesis undergoing primary <3-level lumbar fusion from 2007 to 2016 were gathered from a comprehensive insurance database. Records were queried by International Classification of Diseases diagnosis/procedure codes and insurance-specific generic drug codes. Opioid use 6 months prior, through 2 years after surgery was assessed. Multivariate regression analysis was employed to investigate independent predictors of opioid use following lumbar fusion.

RESULTS

A total of 13 257 patients underwent <3-level posterior lumbar fusion. The cohort racial distribution was as follows: 80.9% white, 7.0% black, 1.0% Hispanic, 0.2% Asian, 0.2% North American Native, 0.8% "Other," and 9.8% "Unknown." Overall, 57.8% patients utilized opioid medications prior to index surgery. When normalized by the number opiate users, all racial cohort saw a reduction in pills disbursed and dollars billed following surgery. Preoperatively, Hispanics had the largest average pills dispensed (222.8 pills/patient) and highest average amount billed ($74.67/patient) for opioid medications. The black cohort had the greatest proportion of patients utilizing preoperative opioids (61.8%), postoperative opioids (87.1%), and long-term opioid utilization (72.7%), defined as use >1 year after index operation. Multivariate logistic regression analysis indicated Asian patients (OR 0.422, 95% CI 0.191-0.991) were less likely to use opioids following lumbar fusion.

CONCLUSIONS

Racial differences exist in perioperative opioid utilization for patients undergoing lumbar fusion surgery for spinal stenosis or spondylolisthesis. Future studies are needed corroborate our findings.