Survey of opioid tapering practices of pediatric healthcare providers: A national perspective

Deborah Fisher, PhD, RN, PPCNP-BC; Suzanne W. Ameringer, PhD, RN

doi:10.5055/jom.2017.0368

Authors

Deborah Fisher, PhD, RN, PPCNP-BC
Suzanne W. Ameringer, PhD, RN

DOI:

https://doi.org/10.5055/jom.2017.0368

Keywords:

pediatrics, prescriber education, opioid prescribing, opioid withdrawal, survey

Abstract

Objective: The purpose of this study was to describe the current opioid tapering practice.

Design: Cross-sectional, online, survey research.

Participants: Pediatric healthcare providers from a national sample of practicing nurse practitioners, physician assistants, and physicians who participate in five different pediatric pain and/or palliative care list serves.

Results: One hundred four participants responded to the survey. The respondents were predominantly physicians (n = 58, 62 percent). The majority of respondents worked in an academic children's medical center (n = 50, 52 percent). The average number of years in pediatric practice was 16 (mean = 16.33, range of 0-45 years). Of the 104 respondents, only 22 (27 percent) had a written protocol for opioid tapering. Use of expert consultants such as pharmacists or pediatric pain management teams varied. The majority of respondents (n = 46, 44 percent) seldom or never consult a pharmacist. Only 22 percent (n = 17) almost always or always consult a pediatric pain team. There was a wide range of personal tapering rate preferences.

Conclusions: This study provided a baseline assessment of pediatric opioid tapering practices by pediatric healthcare providers. Results revealed a marked variation in practice patterns that may indicate deficits in the assessment and management of opioid withdrawal in children. The need for the development of assessment-based opioid tapering guidelines for the pediatric population is long overdue.

Author Biographies

Deborah Fisher, PhD, RN, PPCNP-BC

PANDA Team, Palliative Care, Division of Hospitalist Medicine, Children’s National Medical Center, Washington, DC

Suzanne W. Ameringer, PhD, RN

Virginia Commonwealth University School of Nursing, Richmond, Virginia

References

Ameringer S, Fisher D, Sreedhar S, et al.: Pediatric pain management education in medical students: Impact of a web-based module. J Palliat Med. 2012; 15: 978-983.

Chen I, Goodman B, 3rd, Galicia-Castillo M, et al.: The EVMS pain education initiative: A multifaceted approach to resident education. J Pain. 2007; 8: 152-160.

Doorenbos AZ, Gordon DB, Tauben D, et al.: A blueprint of pain curriculum across prelicensure health sciences programs: One NIH Pain Consortium Center of Excellence in Pain Education (CoEPE) experience. J. Pain. 2013; 14: 1533-1538.

Tauben DJ, Loeser JD: Pain education at the University of Washington School of Medicine. J. Pain. 2013; 14: 431-437.

Berry P, Dahl JL, Donovan MI, et al.: Improving the Quality of Pain Measurement through Measurement and Action. 2003. Available at http://www.npcnow.org/system/files/research/download/Improving-the-Quality-of-Pain-Management-Through-Measurement-and-Action.pdf. Accessed January 2, 2017.

CDC: Opioid Painkiller Prescribing, Where You Live Makes a Difference. Atlanta, GA: Centers for Disease Control and Prevention, 2014.

Manchikanti L, Helm S, 2nd, Fellows B, et al.: Opioid epidemic in the United States. Pain Phys. 2012; 15: ES9-ES38.

Fortuna RJ, Robbins BW, Mani N, et al.: Dependence on emergency care among young adults in the United States. J Gen Intern Med. 2010; 25: 663-669.

Mezei L, Murinson BB, Johns Hopkins Pain Curriculum Development Team: Pain education in North American medical schools. J. Pain. 2011; 12: 1199-1208.

Yanni LM, Priestley JW, Schlesinger JB, et al.: Development of a comprehensive e-learning resource in pain management. Pain Med. 2009; 10: 95-105.

Franck LS, Harris SK, Soetenga DJ, et al.: The Withdrawal Assessment Tool-1 (WAT-1): An assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med. 2008; 9: 573-580.

Ista E, de Hoog M, Tibboel D, et al.: Psychometric evaluation of the Sophia Observation withdrawal symptoms scale in critically ill children. Pediatr Crit Care Med. 2013; 14: 761-769.

da Silva PS, Reis ME, Fonseca TS, et al.: Opioid and benzodiazepine withdrawal syndrome in PICU patients: Which risk factors matter? J Addict Med. 2016; 10: 110-116.

Ista E, van Dijk M, Gamel C, et al.: Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation. Crit Care Med. 2008; 36: 2427-2432.

Fisher D, Grap MJ, Younger JB, et al.: Opioid withdrawal signs and symptoms in children: Frequency and determinants. Heart Lung. 2013; 42: 407-413.

Best KM, Asaro LA, Franck LS, et al.: Randomized evaluation of sedation titration for respiratory failure baseline study I. Patterns of sedation weaning in critically ill children recovering from acute respiratory failure. Pediatr Crit Care Med. 2016; 17: 19-29.

Franck LS, Scoppettuolo LA, Wypij D, et al.: Validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients. Pain. 2012; 153: 142-148.

Anand KJ, Arnold JH: Opioid tolerance and dependence in infants and children. Crit Care Med. 1994; 22: 334-342.

Ducharme C, Carnevale FA, Clermont MS, et al.: A prospective study of adverse reactions to the weaning of opioids and benzodiazepines among critically ill children. Intensive Crit Care Nurs. 2005; 21: 179-186.

Berens RJ, Meyer MT, Mikhailov TA, et al.: A prospective evaluation of opioid weaning in opioid-dependent pediatric critical care patients. Anesth Analg. 2006; 102: 1045-1050.

Katz R, Kelly HW, Hsi A: Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion. Crit Care Med. 1994; 22: 763-767.

Franck LS, Naughton I, Winter I: Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients. Intensive Crit Care Nurs. 2004; 20: 344-351.

Fisher D: Opioid tapering in children: A review of the literature. AACN Adv Crit Care. 2010; 21: 139-145.

Playfor S, Jenkins I, Boyles C, et al.: Consensus guidelines on sedation and analgesia in critically ill children. Intensive Care Med. 2006; 32: 1125-1136.

Galinkin J, Koh JL, Committee on Drugs, et al.: Recognition and management of iatrogenically induced opioid dependence and withdrawal in children. Pediatrics. 2014; 133: 152-155.

Meyer MM, Berens RJ: Efficacy of an enteral 10-day methadone wean to prevent opioid withdrawal in fentanyl-tolerant pediatric intensive care unit patients. Pediatr Crit Care Med. 2001; 2: 329-333.

Robertson RC, Darsey E, Fortenberry JD, et al.: Evaluation of an opiate-weaning protocol using methadone in pediatric intensive care unit patients. Pediatr Crit Care Med. 2000; 1: 119-123.

Ista E, van Dijk M, Gischler S, et al.: Weaning of opioids and benzodiazepines at home after critical illness in infants: A cost-effective approach. J Opioid Manag. 2010; 6: 55-62.

Gowing L, Farrell M, Ali R, et al.: Alpha(2)-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2016: CD002024.

Dowell D: CDC guideline for prescribing opioids for chronic pain-United States. In Haegerich TM (ed.): Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, 2016: 1-49.