Pediatric Providers

We convened a multidisciplinary working group at Michigan Medicine with representatives from Surgery, Anesthesiology, Nursing, Pharmacy, Child Life, and Psychology, who provide care for patients and families after surgery. Together, we discussed concerns about postoperative pain and formulated a common message about how to best manage it. We encourage you to consider doing the same at your institution.

Michigan Medicine’s multidisciplinary working group developed these best practices:

Prescribe Acetaminophen and Ibuprofen

Since acetaminophen and ibuprofen are available over the counter and don’t require a prescription for patients to use, patients and caregivers often do not receive instructions on how to use them after surgery. The packaging instructions for acetaminophen and ibuprofen provide dosing for an age and weight range and recommend as-needed use. If families follow these instructions, they may be under-dosing their children and inadequately addressing their pain. And if they were prescribed an opioid, they may think this is the first medication they should use for their child’s pain, not understanding that acetaminophen and ibuprofen often provide adequate pain relief when dosed and administered correctly and that an opioid may not be needed.

Your Guidance Can Make a Difference

At Michigan Medicine, acetaminophen and ibuprofen are sent electronically as prescriptions to a patient’s pharmacy. When acetaminophen and ibuprofen are written as prescriptions and instructions on how to use them are provided, families then have clear information regarding dosing and understand these are the first-line medications for pain management. Some insurance companies may cover the cost of these medications when they are written as a prescription.

• • • For mild pain, these are used either individually or together on an as-needed basis.
    • For moderate pain, they are given on a schedule together every 6 hours during the day, and at night as needed (if the patient wakes) for 1-2 days after surgery, and then as needed.
    • For severe pain, they are given on a schedule together around the clock for 2 days after surgery and then as needed.

Give Acetaminophen and Ibuprofen Together

Many families are familiar with using acetaminophen and ibuprofen on an alternating basis as-needed for fever and assume they should use them for pain control in the same way. However, from a pain management standpoint, the half-life of both of these medications is long enough that they can be given together.

Giving these two different medications at the same time has benefits:

• Much simpler for families
• Decreases the likelihood of missing or duplicating a dose
• Less disruptive to both sleep and daytime schedules

Simultaneous administration may also allow for longer-lasting pain management. For this reason, we strongly recommend administering acetaminophen and ibuprofen together for pain management. Provide caregivers with information about how to administer these two medications together for pain relief after surgery.

NOTE:

• Avoid ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs) in patients with bleeding disorders, renal disease, peptic ulcer disease, and for specific operations at surgeon discretion.
• Do not use ibuprofen in children under 6 months of age.
• Use only one NSAID at a time (do not combine NSAIDs).
• Use caution when prescribing acetaminophen in patients with hepatic impairment or active liver disease.

OPEN conducted a survey of caregivers for pediatric (under 18) postoperative patients at Michigan Medicine from 2020 through 2022. Over 1,000 surveys have been completed for pediatric patients undergoing a variety of surgical procedures through spring 2022. Procedures were selected based on the frequency with which they occurred and/or associated opioid prescriptions. Eligible patients and their caregivers were called to ask about the quantity and duration of opioid use, use of over-the-counter pain medications, pain score, and overall satisfaction with post-surgical pain management. Patient demographic information, procedure type, and opioid prescription data were gathered from electronic health records and matched with survey information to analyze prescribing patterns, compare pain management, and assess for evidence of overprescribing. Prescribing recommendations were then developed based on actual use, patient reported outcomes, and expert consensus. Many of our patient-reported outcome surveys show opioids are prescribed in greater quantities than patients take and stay in the home after surgery, remaining a persistent source for misuse and diversion.

At Michigan Medicine, they use the Epic electronic medical record system. When patients are discharged after surgery, providers use a discharge order set that contains instructions on postoperative care. Standard orders for acetaminophen and ibuprofen and instructions on their use have been added to the postoperative order sets. This simplifies the process of prescribing for providers and removes the barrier of additional work.

It also allows for standard weight-based dosing and instructions, and offers the opportunity for families to receive the medication at a pharmacy (where it may be covered by insurance). Providing the medications as a prescription validates these over-the-counter medications as the first-line choice for pain management and ensures patients receive the appropriate dose for their size.

Michigan Medicine Patient Education on Order Set

This information is contained in the order set and prints as part of the patient’s After Visit Summary discharge paperwork.

If medication is needed to manage your child’s pain after surgery, the best medications to begin with are over-the-counter pain medicines. These are acetaminophen (example: Tylenol®) and ibuprofen (example: Motrin® or Advil®).

• Do NOT give ibuprofen to children under 6 months of age or if your child’s doctor has told you not to use it.
• Do NOT give any medications in higher amounts or more often than instructed.

Give over-the-counter pain medications:

• Start with a dose of Motrin® and Tylenol® together
• 6 hours later give another dose of Motrin® and Tylenol® together
• If your child is prescribed both Tylenol and Motrin, the best way to control their pain is to give the medications  TOGETHER every 6 hours.

Tips for giving medication safely:

• For liquid medications, check the concentration on the bottle to make sure you’re giving the correct milligram based dose.
• Only use an oral syringe or medication cup to dose correctly. If a dosing tool does not come with the medication, ask the pharmacy for one.
• Household spoons are not accurate to measure medications.
• If your child resists taking the medication, use the syringe to squirt small amounts of medicine into the side of their cheek. This prevents gagging and your child is less likely to spit out the medication.
• If your child is resistant to taking pain medication, you may try mixing it with a food or syrup your child enjoys. Some mixes that have worked for other children include mixing medicine with a popsicle to make a slushy or adding chocolate syrup or applesauce.
• Be careful if you are mixing medication with a food your child enjoys in hopes of making it easier for them to take. If you do this, only mix the medication into a small spoonful of food. Otherwise, if they don’t finish it, you won’t know how much medication they took.
• You can also use other non-medication approaches to manage your child’s pain. These include spending time with them, playing or doing special projects, eating special foods, watching their favorite shows or movies, and using a cold or warm pack.

In children, opioids are prescribed based on weight (mg/kg) up to a maximum weight of 50 kg. However, most oral opioids have a small volume of distribution and are not well absorbed by fat. If obese children are dosed based on their actual weight, they are at greater risk for complications or side effects compared to children in a lower weight category. In addition, a number of overweight and obese children have comorbid sleep-disordered breathing and are already at higher risk for respiratory complications related to opioid use.

How should opioids be prescribed for overweight and obese children to ensure they do not receive higher doses than are safe?

Optimally, body mass index (BMI) would be considered when dosing opioids. If BMI falls outside of the healthy weight range, providers should not follow strict weight-based dosing and instead consider using ideal body weight, lean body mass or lower dose per kg reference. A recent review performed at Michigan Medicine shows that children with BMI in the overweight and obese categories are receiving more morphine milligram equivalents compared to their peers who fall into a healthy weight category.  Further research is necessary to determine how to best calculate opioid dosing in overweight and obese children.

The following best practices were adapted from the Prescription Drug and Opioid Abuse Commission (PDOAC) prescribing recommendations, which were created in partnership with OPEN and the University of Michigan Injury Prevention Center. These strategies have been implemented at Michigan Medicine since 2019.

NOTE:

• Do NOT prescribe codeine or tramadol. Due to pharmacogenetic differences, codeine and tramadol are poor choices for pain management and should not be prescribed.
• Do NOT prescribe fentanyl or long-acting opioids (e.g. methadone, OxyContin®).
• AVOID prescribing opioids that contain acetaminophen (e.g. Norco®, Vicodin®, Percocet®) to minimize risk of
  acetaminophen overdose.
• AVOID prescribing opioids with other sedative medications (e.g., benzodiazepines, skeletal muscle relaxants).
  • If concurrent prescribing is necessary (e.g., to manage postoperative muscle spasms), educate the patient and family about the increased risks of sedation and respiratory depression and consider co-prescribing naloxone.
  • For additional information about naloxone, refer to https://michigan-open.org/medic/.

Prescription drug monitoring programs (PDMPs) are state-level electronic databases that track prescriptions for controlled substances such as opioids. (Reference 14) All 50 states and the District of Columbia have implemented PDMPs in an effort to improve risky opioid prescribing practice and keep patients safe and informed. (Reference 15)

In Michigan, the PDMP is the Michigan Automated Prescription System (MAPS). Michigan law requires that a query of MAPS be performed when an opioid supply of three days or more is prescribed for a patient. It is good practice to check MAPS prior to prescribing any opioid or controlled substance, regardless of duration.

We Can Make PDMPs More Effective

For PDMPs to be most effective, states must work together to improve accessibility, ease of use, and the transparency of PDMPs across state lines. Electronic interstate data sharing will aid in increasing PDMP data’s utility, enhancing patient care, and avoiding drug diversion and misuse. This is crucial as evidence suggests that patients cross state lines in order to seek pain management options and avoid detection by PDMPs.16 In addition, integration of EHR systems, real-time data updates, improved accessibility and ease of use, and access delegation are all critical facilitators that may help improve PDMP implementation and efficacy. (Reference 17)

Support Integration of  PDMP access into the EHR
Integration may lead to greater efficiency by:

• Reducing the time and effort providers need to access patients’ prescription histories
• Allowing providers to both interact with patients and obtain pertinent information in one step

Use PDMPs before and after prescribing opioids
Once every quarter, the Michigan Department of Regulation and Licensing sends providers a report of the controlled substances they have prescribed for patients. To assess for ongoing use in patients who have received new opioid prescriptions, consider checking another MAPS report on the patients on your report.

As prescribers write for fewer opioids, there may be concern about possible increase in phone calls for refills or inadequate pain management. In fact, single institution studies found that with appropriate patient education, not only did patients consume less medication, but requests for refills did not increase. (Reference 18) To ensure appropriate pain management, all patients and families should receive preoperative counseling about postoperative pain and how to manage it.

While a prescription from a surgeon may be the initial point of opioid exposure for a patient, the relationship a surgeon has with a patient is often episodic and as a result, signs of ongoing use or misuse may not be identified. A primary care provider has a longitudinal relationship with the patient and can be better equipped to identify persistent use, misuse, or onset of substance use disorder. However, primary care providers are often unaware that their patients have received an initial opioid prescription from their surgeon. Providing a primary care provider with information about their patient’s operative procedure and the plan for management of acute postoperative pain (especially if that plan includes an opioid prescription) allows for better communication, consistent messaging, and improved patient monitoring after surgery.

The goal of this communication is to let the primary care provider know that their patient had surgery, when it occurred, the plan for pain management, whether an opioid was prescribed and, if so, how much was dispensed, and the expectations in terms of pain duration and plan for refills (if any).

Ideas in terms of sharing this information include using the capability of the electronic medical record to auto-populate a letter or communication to the primary care provider containing this information. If an after-visit summary is created by your electronic medical record, you might forward a copy of this automatically to the primary care provider. Providers could also add standard language to their operative notes containing this information and forward the operating report to the primary care provider.