Eliminating Unnecessary Opioid Exposure After Common Children’s Surgeries

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

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).

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%).

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).

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.^3-5 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

Corresponding Author: Calista M. Harbaugh, MD, MS, Department of General Surgery, Michigan Medicine, 1500 E Medical Center Dr, Taubman Center Room 2110, Ann Arbor, MI 48109-5346 (calistah@med.umich.edu).

Published Online: September 4, 2019. doi:10.1001/jamasurg.2019.2529

Author Contributions: Dr Harbaugh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Harbaugh, Vargas, Li, Thatcher, Waljee, Gadepalli.

Acquisition, analysis, or interpretation of data: Harbaugh, Vargas, Streur, Thatcher, Waljee, Gadepalli.

Drafting of the manuscript: Harbaugh, Vargas, Waljee.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Harbaugh.

Administrative, technical, or material support: Vargas, Gadepalli.

Supervision: Streur, Li, Waljee, Gadepalli.

Conflict of Interest Disclosures: Dr Gadepalli reported grants from Blue Cross Blue Shield foundation during the conduct of the study. Dr Waljee receives research funding from the American College of Surgeons, the American Foundation for Surgery of the Hand, the National Institutes of Health (R01DA042859), the Substance Abuse and Mental Health Services Administration (E20180568-001), the Centers for Disease Control, and the Michigan Department of Health and Human Services.

Funding/Support: This study was supported in part by Blue Cross Blue Shield of Michigan.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors thank Lauren Bohm, MD, and David Zopf, MD (Division of Pediatric Otolaryngology, Department of Otolaryngology, Michigan Medicine, Ann Arbor), for clinical expertise and Kenneth Sloss, BA, Anne Patterson, BA, and Kylie Schafer, BA (Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor), for data collection, for which they were not compensated beyond their usual salary.