Opioid Prescribing

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills

Supporting Literature

Chung et al. 2018 (Level 3 evidence)

• doi: 10.1542/peds.2017-2156
• Retrospective cohort study that analyzed the prevalence of and indications for outpatient opioid prescriptions and the incidence of opioid-related adverse events in children undergoing dental extraction at a single institution between 1999-2014.
• 1362503 outpatient opioid prescriptions; The annual mean prevalence of opioid prescriptions was 15%
• 437 cases of opioid-related adverse events confirmed by medical record review; 88.6% were related to the child’s prescription and 71.2% had no recorded evidence of deviation from the prescribed regimen.
• Adverse events increased with age and higher opioid dose. Adverse events accounted for 38.3% of prescriptions.

Chua et al. 2021(Level 3 evidence)

• doi:10.1016/j.amepre.2021.02.008.
• Used IBM MarketScan Dental, Commercial, and Medicaid Multi-State Databases to analyze data from privately and publicly insured patients aged 13–64 years who underwent a dental extraction between 2011-2018. Included 8,544,098 procedures among 5,562,589 unique patients.
• When ≥1 initial prescription did occur the 90-day risk of overdose was 5.8 per 10,000 procedures and the 90-day risk of overdose in a family member was 1.7 per 10,000 procedures.
• When ≥1 initial prescription did not occur, the 90-day risk of overdose was 2.2 per 10,000 procedures and the 90-day risk of overdose in a family member was 1.0 per 10,000 procedures.

Moore & Hersh 2013 (Level 4 evidence).

• doi: 10.14219/jada.archive.2013.0207
• Systematic review to determine the safety and analgesic efficacy of combining ibuprofen and N-acetyl-p-aminophenol (APAP).
• Found that ibuprofen and APAP may be a more effective analgesic with fewer side-effects than current treatments for third molar extractions.
• Number of doses of ibuprofen + APAP to treat pain = 1.6

Data Analysis

Harbaugh et al. 2019 (Level 3 evidence)

• DOI: 10.1001/jamasurg.2019.2529
• Included Procedures: Laproscopic Appendectomy
• April 2018 – November 2018
• 59 Patients
• 97% of patients (57/59) were not prescribed or did not use opioids following surgery

Supporting Literature

Kelley-Quon et al. 2022 (Level 2 evidence)

• DOI: http://doi.org/10.1097/XCS.0000000000000056
• Analyzed data from 1,524 children who underwent appendectomy at 10 institutions from January-December 2019.
• Opioid prescribing can be minimized using institutional protocols.
• After intervention, overall prescribing decreased from 18.2% to 4% and mean pain satisfaction scores were high.

Cina et al. 2022 (Level 2 evidence)

• DOI: http://doi.org/10.1016/j.jpedsurg.2022.04.019
• Retrospective study of appendectomy patients (average age 11yo) and opioid prescribing/consumption patterns.
• Analyzed data from 1,789 pediatric patients who underwent an appendectomy at a single institution between January 2014-December 2017.
• Older age, previous opioid exposure, and shorter hospital stay are associated with increased risks of chronic opioid use.

Creamer et al. 2020 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2020.09.067
• Retrospective study of appendectomy patients (median ge of 10yo) and pain scores, opioid exposure, and discharge opioid prescribing habits.
• Analyzed data from 258 pediatric patients who underwent an appendectomy at a single institution between 1 April- 31 December 2018.
• Post-guidelines there was a significant decrease in the number of doses of opioids, length of hospitalization, and days of opioid exposure.
• Number of doses pre-guideline = 0-26.
• Number of doses post-guideline = 0-11.

Manworren et al. 2021 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.pmn.2021.02.011
• Prospective exploratory and descriptive study of appendectomy patients.
• Analyzed data from 96 pediatric patients (mean age of 14yo) who underwent a laparoscopic appendectomy at a single institution.
• Prescribed 16 ± 6.5 opioid pills to treat pain at home. Patients used 6.6 ± 6.3 pills by pill count but self-reported 5.6 ± 5.1 pills.
• Of the 749 opioid-containing pills prescribed to 49 patients who returned data, 689 pills (92%) were dispensed, 167.5 (22.4%) were used for the reason prescribed, 488 (65.2%) were returned to families for disposal, and 53.5 (7.1%) were missing.

Freedman-Weiss et al., 2020 (Level 2 evidence)

• DOI: 10.1016/j.jpedsurg.2019.09.063
• Patients 5-20 years old who underwent laparoscopic appendectomy
• 77 patients consented, 49 completed interview. Of these, 7 either wanted opioid or used opioid. Avg MME 3 doses.
• Main outcomes: quantity of opioids used, desire for an opioid, presence of pain ≥ 4/10, and need for follow-up/ call owing to pain
• 83% did not use or desire an opioid and reported pain < 4/10 after discharge.
• 86% interviewed satisfied without use opioid.
• No zero-opioid patients had unanticipated follow-up for pain concerns
• Conclusion: recommend acetaminophen and ibuprofen as main form of pain management. If prescribing opioids, consider maximum of 3 doses for population most at risk of uncontrolled pain (male adolescents, those discharged rapidly after surgery, those using inpatient opioids).

Data Analysis

Harbaugh et al. 2019 (Level 3 evidence)

• DOI: 10.1001/jamasurg.2019.2529
• Included Procedures: Inguinal Herniorrhaphy, Hydrocelectomy
• April 2018 – November 2018
• 84 Patients
• 88% of patients (74/84) were not prescribed or did not use opioids following surgery

Supporting Literature

Chiem et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1097/pq9.0000000000000548
• 641 patients (3yo-18yo) were assigned to study groups based on time period, and were given either standard anesthesia, multimodal anesthesia, or opioid-free anesthesia for inguinal hernia repair. Pain scores were measured.
• Opioids can be safely minimized without sacrificing satisfaction with pain management. Only 12% of patients required a rescue dose of morphine in PACU.

Hageman et al. 2022 (Level 3 evidence)

• DOI: 0.1016/j.jpedsurg.2022.02.039
• Retrospective review of 15 studies were compared with a retrospective review of patients at the authors’ institution. Opioid use was analyzed.
• Opioids were mostly administered while admitted during the first 24h after surgery. One institution uses opioids sparingly in PACU and successfully eliminated opioid prescriptions at discharge.

Svetanoff et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2021.10.012
• Patients were contacted 1-4 weeks after different surgeries and were surveyed about opioid use. Results between procedure types were compared.
• 89% of inguinal hernia patients filled opioid scripts at discharge, and 91% of those opioids went unused. 94% of patients using non-opioid pain relief methods were satisfied with pain management.

Data Analysis

Harbaugh et al. 2019 (Level 3 evidence)

• DOI: 10.1001/jamasurg.2019.2529 Included Procedures: Umbilical or Epigastric Herniorrhaphy
• April 2018 – November 2018
• 31 Patients
• 97% of patients (30/31) were not prescribed or did not use opioid following surgery

Supporting Literature

Slater et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2021.08.004
• Opioid education was administered to providers, and opioid prescribing data was collected before and after the education was administered.
• There was a significant and sustainable decrease in opioid prescribing (75.8% vs. 22.8% of patients) after administering opioid education to providers.

Harbaugh et al, 2019

• DOI: 10.1001/jamasurg.2019.2529
• 31 patients. 30/31 were not prescribed or did not use opioid.

Data Analysis

Harbaugh et al. 2019 (Level 3 evidence)

• DOI: 10.1001/jamasurg.2019.2529 Included Procedures: Adenoidectomy
• April 2018 – November 2018
• 81 Patients
• 94% of patients (76/81) were not prescribed or did not use opioid following surgery

Supporting Literature

Viitanen et al. 2003 (Level 1 evidence)

• DOI: http://doi.org/10.1093/bja/aeg196
• Randomized controlled trial with 160 children (1yo-6yo) undergoing adenoidectomy were randomized to receive one of the following rectal medications: acetaminophen; ibuprofen; acetaminophen with ibuprofen; or placebo.
• Intraoperative use of rectal acetaminophen and ibuprofen reduces need for oral analgesia after discharge.

Alghamdi et al. 2020 (Level 3 evidence)

• DOI: http://doi.org/10.2147/JPR.S281275
• 10 patients (3yo-8yo) were given opioid-free anesthesia for adenoidectomy and pain scores were measured.
• Opioids can be safely eliminated without sacrificing satisfaction with pain management.

Harbaugh et al. 2019 (Level 3 evidence)

• DOI: 10.1001/jamasurg.2019.2529
• Analyzed data from 404 children undergoing umbilical or epigastric herniorrhaphy; laparoscopic appendectomy; inguinal herniorrhaphy and/or hydrocelectomy; adenoidectomy; circumcision; percutaneous pinning for elbow fracture or scrotal-incision orchiopexy at a single institution between April 2018- November 2018
• 22% of patients received a discharge opioid with a median of 10 doses.
• Nearly 90% of patients undergoing an adenoidectomy were not prescribed or did not use an opioid.
• 88% of patients reported acetaminophen use and 78% reported ibuprofen use for a median of 3 days.
• Conclusion: Postoperative opioid prescribing for children is unnecessary following adenoidectomy with adequate analgesia on nonopioid analgesics

Data Analysis

• Included Procedures: Cochlear Implant, Tympanoplasty and mastoidectomy, Mastoidectomy, Tymplanoplasty
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine
• March 2021 – August 2022
• 40 Opioid Naïve Patients
• Pain Score (median): 2
• Satisfaction with Pain Management (median): 5

Data Analysis

• Included Procedures: Tonsillectomy, Tonsillectomy and Adenoidectomy
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine
  March 2021 – August 2022
• 138 Opioid Naïve Patients
  
• Pain Score (median): 3
• Satisfaction with Pain Management (median): 5

Supporting Literature

Commesso et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.ijporl.2022.111337
• Analyzed data from pediatric patients <18yo undergoing adenotonsillectomy at a single tertiary academic healthcare institution between 2013-2016.
• 69% prescribed opioids and 51% prescribed non-opioid analgesics.
• Patients prescribed opioids had a higher rate of emergency department presentation (17.4% compared to 11.3%).
• For patients presenting to the emergency department (ED) within 30 days, 77% had an opioid prescription and 19% had an acetaminophen prescription at the time of surgery.
• Recommendation = prescribe acetaminophen to reduce 30-day ED presentation rate.

Supporting Literature

Chua et al. 2022 (Level 2 evidence)

• DOI: http://doi.org/10.1001/jamanetworkopen.2022.19701
• Analyzed data from 237 individuals age 12-50 undergoing tonsillectomy at a single medical center from 1 October 2019- 31 July 2021.
• Mean number of doses prescribed post-intervention = 16.1.
• Recommendation for prescription = 12 doses

Data Analysis

• Included Procedures: Cleft lip Repair or Revision, Alveolar Cleft Bone Graft, Pharyngeal Flap/Pharyngoplasty, Dynamic Sphincteroplasty, Dynamic Sphincter Pharyngoplasty
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine 
• March 2021 – August 2022
• 55 Opioid Naïve Patients
• Pain Score (median): 3
• Satisfaction with Pain Management (median): 5

Supporting Literature

Zubovic et al., 2023 (Level 3 evidence)

• DOI: 10.1177/10556656221083082.
• 133 pediatric patients undergoing cleft lip and/or palate (90) or craniosynostosis repairs (43)
• Reviewed pediatric opioid prescriptions from July 2018- June 2019 and surveyed patients on actual opioid use from August 2019-February 2020
• Median prescribed opioid doses for cleft lip and/or palate = 10.3 (range 0-75)
• Median prescribed opioid doses for craniosynostosis = 14.3 (range 0-50)
• Patients report consuming < 11 doses: 40% used 0, 33% used 1-2, 18% used 3-5, and 9% used 6-10
• Conclusion: Actual home opioid use is less than prescribed amounts, with almost half using 0 opioids

Data Analyses

• Included Procedures: Circumcision
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine March 2021 – August 2022
• 68 Opioid Naïve Patients
• Pain Score (median): 2
• Satisfaction with Pain Management (median): 5

Supporting Literature

Koo et al. 2020 (Level 4 evidence)

• doi: 10.1097/JU.0000000000000514
• 15-member multidisciplinary expert panel used a 3-step modified Delphi method to develop recommendations for postoperative opioid prescribing. Recommendations were for opioid naive patients without chronic pain conditions and included 16 endourological and minimally invasive urological procedures.
• Recommended prescription = 0-15 tablets
• Supports contextualizing postoperative pain management with patient goals and preferences and maximizing nonopioid therapies.

Grau et al. 2019 (Level 2 evidence)

• doi: 10.1097/JU.0000000000000020
• Assessed the impact of a 2-phase Plan-Do-Study-Act cycle to decrease opioid prescriptions following pediatric urological surgery.
• Analyzed data pertaining to opioid dosing and pain scores. Included 25 children at a single institution from 2016-2017.
• No significant differences were found between pain scores in the 5-dose group (31 patients) and the 10-dose group (24 patients).
• Previous recommendation = 10 doses over 5 days
• New recommended prescription = 0-2 doses

Corona et al. 2019 (Level 3 evidence)

• doi: https://doi.org/10.1016/j.jpurol.2021.01.008
• Evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major institutions (Michigan Medicine & University of Wisconsin) between 2016-2017.
• Included 811 circumcisions and 883 inguinal surgeries.
• Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery.
• 95.4% of patients received an opioid prescription, 75% of whom received a prescription for 15 doses or more
• Median number of doses prescribed for circumcision = 20
• Younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed.

Harbaugh et al. 2019 (Level 3 evidence)

• DOI: 10.1001/jamasurg.2019.2529
• Analyzed data from 404 children undergoing umbilical or epigastric herniorrhaphy; laparoscopic appendectomy; inguinal herniorrhaphy and/or hydrocelectomy; adenoidectomy; circumcision; percutaneous pinning for elbow fracture or scrotal-incision orchiopexy at a single institution between April 2018- November 2018
• Caregivers were contacted 7 and 21 days after procedure regarding pain control and analgesic use.
• Included 65 circumcisions
• A discharge opioid was prescribed to 22% of patients with median 10 doses (range of 6-15 pills)
• Nearly 80% of patients undergoing a circumcision were not prescribed or did not use an opioid
• Only 1 in 3 patients used an opioid, typically for 3 days or less

Data Analysis

• Included Procedures: Hydrocelectomy, Orchidopexy, Laparoscopic Assisted Orchidopexy
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine
• March 2021 – August 2022
• 84 Opioid Naïve Patients
• Pain Score (median): 2
• Satisfaction with Pain Management (median): 5

Data Analysis

• Included Procedures: Hypospadias Repair
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine
  March 2021 – August 2022
• 28 Opioid Naïve Patients
  
• Pain Score (median): 3
• Satisfaction with Pain Management (median): 5

Data Analysis

• Included Procedures: Chordee Release, Meatoplasty Or Meatotomy, Penile Webbing Release/ Lysis Of Adhesions
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine
  March 2021 – August 2022
• 29 Opioid Naïve Patients
• Pain Score (median): 2
• Satisfaction with Pain Management (median): 5

Supporting Literature

Bilgutay et al., 2019 (Level 3 evidence)

• DOI: 10.1016/j.purol.2019.10.021
• 200 pediatric patients, aged 6 months to 18 years, undergoing outpatient urologic surgeries, such as circumcision, orchiopexy, division of penile bands, inguinal hernia repair, meatoplasty, phalloplasty, hypospadias repair, inguinal orchiectomy, scrotal hydrocele, and excision of penile lesion
• Median number of opioid doses prescribed = 10
• Mean number of opioid doses used = 1.28
• Median number of excess doses prescribed per patient = 10
• No difference in amount of opioid used based on procedure
• Conclusion: Majority of pediatric patients used 0-2 doses of prescription pain medication after discharge, representing a small percentage of the total prescribed amount

Data Analysis

• Included Procedures: Extravesical Ureteral Reimplant – Unilateral or Bilateral, Intravesical Ureteral Reimplant – Unilateral or Bilateral
• Patient Reported Outcomes data collected via C.S. Mott Children’s Hospital, Michigan Medicine
  March 2021 – August 2022
• 25 Opioid Naïve Patients
  
• Pain Score (median): 2
• Satisfaction with Pain Management (median): 5