Opioid prescription rates in adolescents following surgery
Myron Yaster MD and Rita Agarwal MD FAAP
As many of my friends and colleagues and the readers of the PAAD know, I’ve been interested in opioid prescribing practices in pediatrics and what happens to left over, unconsumed opioids for more than a decade. Indeed, my colleagues at Johns Hopkins and I were amongst the first to sound the alarm about over-prescription of opioids in children and the lack of education on safe use, storage and disposal of these medications .1-4
Dr. Rita Agarwal, the primary reviewer of pain articles for the PAAD, has been working with the American Academy of Pediatrics (AAP), the American Medical Association, and other organizations to focus on educating pediatricians’ and other providers who prescribe opioids to children in an attempt to optimize pain management and appropriate opioid prescribing.5 Today’s PAAD by Sofia et al.6 takes another look at national trends in postsurgical opioid prescription rates over time (2015 -2020) among adolescents in the United States. Myron Yaster MD
Original article
Sofia JT, Kim A, Jones I, Rabbitts JA, Groenewald CB. Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020. Paediatr Anaesth. 2023 Dec;33(12):1083-1090. doi: 10.1111/pan.14753. Epub 2023 Oct 4. PMID: 37789737.
The role of prescription opioids, the non-medical use of prescription opioids, and the national opioid epidemic has led to national policies aimed at reducing opioid prescribing practices across all fields of medicine including surgery. In the context of the current fentanyl crisis and the increasing number of opioid (really illegal fentanyl) deaths despite decreasing opioid prescription rates, we and many others, believe that continuing to target physician prescribing practices makes little sense.7 Nevertheless, reducing opioid prescribing is a continuing national policy, particularly for adolescents.
Why adolescents? “Children and adolescents are increasingly recognized as a uniquely vulnerable population.”6,8,9 In addition, 90% of patients who develop substance use disorder as adults start using prescription medication in a manner not prescribed by a physician before the age of 18, and surgery and opioid prescriptions have been shown to be a primary event for many patients who develop SUD.10 The primary aim of Sofia et al.’s study “was to characterize trends in adolescent opioid prescription rates associated with surgery from 2015 to 2020 using a nationally representative large database, the Medical Expenditure Panel Surveys (MEPS).”6
“The MEPS are nationally representative, large-scale surveys conducted annually by the Agency for Healthcare Research and Quality (AHRQ). MEPS participants include parents, children, healthcare providers, insurance providers, and employers across the United States. (http://meps.ahrq.gov/mepsw) The primary purpose of MEPS is to provide comprehensive estimates of health care use, including surgery and prescription opioid use among the noninstitutionalized civilian population of the USA.”
What did they find? “In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%–3.7%, p< .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020).”6
So to be clear, although overall opioid prescribing rates went down, the rate for opioid prescribing in surgical patients did not decrease. We are not surprised. Poorly controlled postoperative surgical pain “is associated with a host of negative consequences, including reduced engagement in post-surgery rehabilitation, delayed functional recovery, and increased risk for chronic postsurgical pain11-13.”6
A troubling finding in this study: “reduced surgery utilization was observed among black and Hispanic populations, as compared to white, non-Hispanic adolescents, and white, non-Hispanic adolescents were more likely to be prescribed an opioid than black or Hispanic adolescents. These findings are broadly consistent with prior work published by our group, which found that between 2003 and 2014, white children were more likely to receive an opioid prescription than black children, Hispanic children, and Asian children.”6
Finally, there were several important limitations in this study. Surgery was defined as “all procedures resulting in skin incision”. This would exclude 3rd molar extractions, one of the largest sources of opioid prescribing in adolescents. At least one study conforms that dental clinicians are a significant source of opioid exposure in adolescents and young adults (AYA).14 In one study 30% of all opioid prescriptions for AYA were written by dental clinicians, with ~6% of those patients requiring at least one additional prescription for opioids 90-365 days later. Even more concerning, 5.8 % of those patients went on to have health care encounters with an opioid abuse-related diagnosis compared to 0.4% of non-opioid exposed patients,
Second, using a database like MEPS, which relies on self report, captures opioid prescribing but not who actually filled their prescriptions, if patients actually took their medication, how much and how long opioid therapy lasted, and what, if anything happened to leftovers.
Do the results of this study jive with what you are experiencing in your practices? Send your thoughts to Myron who will post in a Friday reader response.
References
1. Hunsberger JB, Hsu A, Yaster M, Vozzo PT, Gao S, White ED, Yenokyan G, Vickers B, Monitto CL: Physicians Prescribe More Opioid Than Needed to Treat Pain in Children After Outpatient Urological Procedures: An Observational Cohort Study. Anesth Analg 2020; 131: 866-875
2. Hunsberger JB, Hsu A, Yaster M, Vozzo PT, Gao S, White ED, Yenokyan G, Vickers B, Monitto CL: Physicians Prescribe More Opioid Than Needed to Treat Pain in Children After Outpatient Urological Procedures: An Observational Cohort Study. Anesth Analg 2019
3. Bicket MC, White E, Pronovost PJ, Wu CL, Yaster M, Alexander GC: Opioid Oversupply After Joint and Spine Surgery: A Prospective Cohort Study. Anesth Analg 2018
4. George JA, Park PS, Hunsberger J, Shay JE, Lehmann CU, White ED, Lee BH, Yaster M: An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions. Anesth Analg 2016; 122: 807-13
5. Agarwal R, Chapman EC, Sedney C: The nation’s drug overdose epidemic—Helping children and families, patients with pain. Edited by Mukkamala B, 2022
6. Sofia JT, Kim A, Jones I, Rabbitts JA, Groenewald CB: Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020. Paediatr Anaesth 2023; 33: 1083-1090
7. Kharasch ED, Clark JD, Adams JM: Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology 2022; 136: 10-30
8. Kelley-Quon LI, Kirkpatrick MG, Ricca RL, Baird R, Harbaugh CM, Brady A, Garrett P, Wills H, Argo J, Diefenbach KA, Henry MCW, Sola JE, Mahdi EM, Goldin AB, St Peter SD, Downard CD, Azarow KS, Shields T, Kim E: Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg 2021; 156: 76-90
9. Renny MH, Yin HS, Jent V, Hadland SE, Cerdá M: Temporal Trends in Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US From 2006 to 2018. JAMA Pediatr 2021; 175: 1043-1052
10. Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R: Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg 2023
11. Rabbitts JA, Palermo TM, Lang EA: A Conceptual Model of Biopsychosocial Mechanisms of Transition from Acute to Chronic Postsurgical Pain in Children and Adolescents. J Pain Res 2020; 13: 3071-3080
12. Rabbitts JA, Fisher E, Rosenbloom BN, Palermo TM: Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis. J Pain 2017; 18: 605-614
13. Rabbitts JA, Palermo TM, Zhou C, Meyyappan A, Chen L: Psychosocial Predictors of Acute and Chronic Pain in Adolescents Undergoing Major Musculoskeletal Surgery. J Pain 2020; 21: 1236-1246
14. Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT: Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med 2019; 179: 145-152