Eliminating Unnecessary Opioid Exposure After Common Children’s Surgeries

Abstract

This study investigates patient-reported opioid consumption after pediatric operations.

From 1999 to 2016, opioid-related overdoses rose by 250% among children and adolescents.¹ Acute pain after surgery or injury is the most frequent indication for pediatric opioid prescribing.² However, prescribing is variable, and little is known regarding patient-reported opioid consumption and pain after pediatric operations to guide opioid prescribing.^3,4

Methods

As part of a multispecialty quality improvement project to reduce opioid prescribing, this study was deemed exempt by the University of Michigan institutional review board. Children younger than 18 years undergoing umbilical or epigastric herniorrhaphy; laparoscopic appendectomy; inguinal herniorrhaphy and/or hydrocelectomy; adenoidectomy; circumcision; percutaneous pinning for elbow fracture (supracondylar, epicondylar, or condylar); or scrotal-incision orchiopexy at a tertiary care facility were screened for eligibility (April 2018 to November 2018). Exclusion criteria were enrollment in another study, admission greater than 7 days, and any previous or concurrent operations during the study period.

Caregivers received pain journals to record postoperative analgesic use. Caregivers were contacted at 7 to 21 days postoperatively by telephone, email, or follow-up appointment regarding pain control and analgesic use. Verbal consent was obtained prior to survey administration. Outpatient opioid prescriptions and emergency department (ED) visits within 30 days of discharge were collected from the electronic medical record. Number of doses was calculated as total quantity divided by minimum dose. Missing responses were excluded on a question-by-question basis (<9%). Pain control, postdischarge prescriptions, and pain-related ED visits were compared among patients with and without discharge opioid prescriptions using Fisher exact tests, with 2-tailed significance of P less than 0.05 (Stata 15, StataCorp).

Results

Among 675 eligible patients, 404 caregivers responded (60%). Of all patients, 293 were boys (73%) with median age 4 years (25th to 75th percentile, 1-7 years). A discharge opioid was prescribed to 88 patients (22%) with median 10 doses (25th to 75th percentile, 6-15). Most respondents reported acetaminophen (88%; n = 348 of 397) and/or ibuprofen use (78%; n = 313 of 397) for a median of 3 days (25th to 75th percentile, 2-5 days). Among 78 respondents prescribed an opioid, opioids were used for median of 2 days (25th to 75th percentile, 1-3 days). Nearly all respondents (n = 70; 90%) used less than prescribed. Most respondents used less than half (n = 29; 37%) or none (n = 24; 31%) of the prescription. Nearly 90% of respondents were not prescribed or did not use opioid after umbilical/epigastric herniorrhaphy (30 of 31 respondents), appendectomy (57 of 59 respondents), inguinal herniorrhaphy/hydrocelectomy (74 of 84 respondents), and adenoidectomy (76 of 81 respondents) (Figure). Opioids were locked in storage by 22 respondents (28%) and disposed by 7 respondents with opioids left over (11%).

Figure. Opioid Prescribing and Use by Pediatric Patients After Common Operations.

For each of 7 common procedures, opioid prescription and parent-reported opioid use was collected. The y-axis demonstrates the proportion of patients for each procedure with each level of reported opioid use. The dark blue bars represent the proportion of patients who did not receive a discharge opioid prescription. The percentages represent the proportion of patients who did not take any opioids (were not prescribed or did not use any of the prescription).

Overall, pain control was reported as good (329 of 403 respondents; 82%), adequate (56 of 403 respondents; 14%), or poor (18 of 403 respondents; 4%). Eight caregivers (2%) requested a postdischarge opioid prescription (median, 13.5 doses; 25th to 75th percentile, 9.5-22.5 doses) for patient pain following adenoidectomy, circumcision, elbow fracture, or orchiopexy on median postoperative day 1 (IQR, 1-3): 4 had no discharge prescription and 4 consumed their discharge prescription. There were 3 ED visits for pain (0.7%): 2 from constipation after appendectomy (no opioid prescription), and 1 from urinary retention after circumcision. Lack of a discharge opioid prescription was not associated with poor pain control (opioid: 3 of 88 respondents [3.4%]; no opioid: 15 of 315 respondents [4.8%]; P = .77), postdischarge opioid prescription (opioid: 4 of 88 respondents [4.6%]; no opioid: 4 of 316 respondents [1.3%]; P = .07), or pain-related ED visit (opioid: 1 of 88 respondents [1.1%]; no opioid: 2 of 316 respondents [0.6%]; P = .52).

Discussion

Postoperative opioid prescribing for children is unnecessary following umbilical/epigastric herniorrhaphy, appendectomy, inguinal herniorrhaphy/hydrocelectomy, and adenoidectomy with adequate analgesia on nonopioid analgesics. Circumcision, elbow fracture, and orchiopexy had the highest opioid use; yet only 1 in 3 patients used an opioid, typically for 3 days or less. Excess opioid medication was often kept unlocked and undisposed. Although more than half of patients were prescribed an opioid in prior studies, postdischarge analgesia and analgesic use were not captured.^3,4,5 This study is limited by the single-center, nonrandomized design; however, the low rates of prescribing and consequent adverse outcomes may supersede the clinical equipoise needed for future randomization. Given the iatrogenic risks of excess opioid, these findings suggest that safe opioid stewardship necessitates elimination of opioid exposure after many common children’s operations.^2,6