Limited use of nonopioid analgesics after pediatric ambulatory surgery

Nhi Ho, MD; Anjali A. Dixit, MD, MPH; Christina Inglis-Arkell, MD; Solmaz P. Manuel, MD

doi:10.5055/jom.2021.0620

Authors

Nhi Ho, MD
Anjali A. Dixit, MD, MPH
Christina Inglis-Arkell, MD
Solmaz P. Manuel, MD https://orcid.org/0000-0002-7061-066X

DOI:

https://doi.org/10.5055/jom.2021.0620

Keywords:

pediatric surgery, postoperative pain, opioid, nonopioid analgesia, multimodal analgesia

Abstract

Objective: This study sought to determine the rate at which nonopioid analgesics were utilized in postoperative pain management plans after pediatric ambulatory surgery in patients who were also prescribed postoperative opioids.

Design: Retrospective cohort analysis.

Participants: Patients ≤ 21 years old who were prescribed opioid medications after undergoing ambulatory surgery at a tertiary-care medical center.

Methods: Postoperative day 1 (POD1) opioid prescription and use survey data along with electronic medical record data were extracted and analyzed for patients meeting inclusion criteria between April 2017 and December 2017.

Main outcome measure: Recommendation to take nonopioid analgesics after discharge.

Results: A total of 849 (63.2 percent) patients responded to the survey and 275 (32.4 percent) of these cases were prescribed postoperative opioids. Of the 273 cases included in this study, 137 (50.2 percent) received recommendations to take at least one nonopioid analgesic as well, and 164 (60.1 percent) reported using their prescribed opioids on POD1. Opioid use did not vary significantly with nonopioid analgesic recommendations. There was significant variability in opioid and nonopioid analgesic prescribing and recommendation patterns across surgical subspecialties.

Conclusions: There was limited use of nonopioid analgesics in postoperative pain management plans after pediatric ambulatory surgery. This leaves many patients with only opioid-based agents as the first-line medication for postoperative pain management. These findings highlight an opportunity to educate prescribers and patients on the importance of step-wise multimodal analgesic plans.

Author Biographies

Nhi Ho, MD

Department of Anesthesiology, University of Southern California School of Medicine, Los Angeles, California

Anjali A. Dixit, MD, MPH

Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington

Christina Inglis-Arkell, MD

Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California

Solmaz P. Manuel, MD

Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California

References

Ceelie I, De Wildt SN, Van Dijk M, et al.: Effect of intravenous paracetamol on postoperative morphine requirements in neonates and infants undergoing major noncardiac surgery: A randomized controlled trial. JAMA. 2013; 309(2): 149-154. DOI: 10.1001/jama.2012.148050.

Munro HM, Walton SR, Malviya S, et al.: Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents. Can J Anaesth. 2002; 49(5): 461-466. DOI: 10.1007/BF03017921.

Wick EC, Grant MC, Wu CL: Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review. JAMA Surg. 2017; 152(7): 691-697. DOI: 10.1001/jamasurg.2017.0898.

Gaither JR, Leventhal JM, Ryan SA, et al.: National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012. JAMA Pediatr. 2016; 170(12): 1195-1201. DOI: 10.1001/jamapediatrics.2016.2154.

Harbaugh CM, Lee JS, Hu HM, et al.: Persistent opioid use among pediatric patients after surgery. Pediatrics. 2018; 141(1): e20172439. DOI: 10.1542/peds.2017-2439.

Allen JD, Casavant MJ, Spiller HA, et al.: Prescription opioid exposures among children and adolescents in the United States: 2000-2015. Pediatrics. 2017; 139(4): e20163382. DOI: 10.1542/peds.2016-3382.

Chou R, Gordon DB, De Leon-Casasola OA, et al.: Management of postoperative pain: A clinical practice guideline from the American pain society, the American society of regional anesthesia and pain medicine, and the American society of anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. J Pain. 2016; 17(2): 131-157. DOI: 10.1016/j.jpain.2015.12.008.

Cravero JP, Agarwal R, Berde C, et al.: The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth. 2019. DOI: 10.1111/pan.13639.

Fricke JR, Karim R, Jordan D, et al.: A double-blind, single-dose comparison of the analgesic efficacy of tramadol/acetaminophen combination tablets, hydrocodone/acetaminophen combination tablets, and placebo after oral surgery. Clin Ther. 2002; 24(6): 953-968. DOI: 10.1016/S0149-2918(02)80010-8.

Harbaugh CM, Nalliah RP, Hu HM, et al.: Persistent opioid use after wisdom tooth extraction. JAMA. 2018. DOI: 10.1001/jama.2018.9023.

Echeverria-Villalobos M, Stoicea N, Todeschini AB, et al.: Enhanced recovery after surgery (ERAS). Clin J Pain. 2020; 36(3): 219-226. DOI: 10.1097/AJP.0000000000000792.