Physicians Prescribe More Opioid Than Needed to Treat Pain in Children After Outpatient Urological Procedures: An Observational Cohort Study.

BACKGROUND: The epidemic of nonmedical use of prescription opioids (NMUPOs) has been fueled in part by the availability of leftover, legitimately prescribed opioids. In children, outpatient urological procedures are among the most common surgeries performed, but data are lacking to guide appropriate postoperative opioid prescribing. The aim of this study was to compare the amount of prescribed opioid medication to the amount taken for acute pain after minor pediatric urological surgery and to determine the disposition of excess opioid. In addition, we explored whether distinct patient characteristics and procedure type influenced opioid prescribing and consumption. METHODS: Of the 139 families of pediatric patients enrolled, 115 were interviewed within 48 hours and/or 10-14 days of discharge to determine the amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. RESULTS: The most common procedures performed were circumcision (n = 58) and orchiopexy (n = 40). Most patients (98%) were male, and 77% were <8 years of age. All opioid prescriptions were for oxycodone dosed every 4 hours as needed (PRN). Median number of doses prescribed was 30 (interquartile range [IQR], 23-31; n = 138) for both respondents who reported doses remaining (IQR, 29-31; n = 83) and those who did not (IQR, 22-32; n = 55). Among those reporting doses remaining, median number of doses consumed was 4.2 (IQR, 0-14). Multivariable linear regression showed no significant association between doses consumed and patient age, type of procedure, discharge pain score, or use of adjuvant analgesics. Median duration of opioid therapy was 2 days (IQR, 0-5; n = 83) with each additional day of opioid use corresponding to an average increase in consumption of 2.3 doses (95% confidence interval [CI], 1.8-2.8). An estimated 75% (95% CI, 69%-81%) of opioid dispensed was not consumed, and 86% (72/83) of patients took ≤18 doses. Forty-four of 65 (68%) families reported receiving no disposal instructions for leftover opioid, and only 7 families disposed of leftover medication. CONCLUSIONS: For minor pediatric urological surgeries in young boys, a 3-day supply (18 doses) of opioid was sufficient to adequately treat acute postoperative pain in most patients. Adjusting opioid dispensing to align with consumption and better educating patients and families on opioid disposal can be used to potentially decrease availability of leftover opioids in homes and communities.

Opioid Prescribing for the Treatment of Acute Pain in Children on Hospital Discharge.

BACKGROUND: The epidemic of nonmedical use of prescription opioids has been fueled by the availability of legitimately prescribed unconsumed opioids. The aim of this study was to better understand the contribution of prescriptions written for pediatric patients to this problem by quantifying how much opioid is dispensed and consumed to manage pain after hospital discharge, and whether leftover opioid is appropriately disposed of. Our secondary aim was to explore the association of patient factors with opioid dispensing, consumption, and medication remaining on completion of therapy. METHODS: Using a scripted 10-minute interview, parents of 343 pediatric inpatients (98% postoperative) treated at a university children's hospital were questioned within 48 hours and 10 to 14 days after discharge to determine amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. Multivariable linear regression was used to examine predictors of opioid prescribing, consumption, and doses remaining. RESULTS: Median number of opioid doses dispensed was 43 (interquartile range, 30-85 doses), and median duration of therapy was 4 days (interquartile range, 1-8 days). Children who underwent orthopedic or Nuss surgery consumed 25.42 (95% confidence interval, 19.16-31.68) more doses than those who underwent other types of surgery (P < .001), and number of doses consumed was positively associated with higher discharge pain scores (P = .032). Overall, 58% (95% confidence interval, 54%-63%) of doses dispensed were not consumed, and the strongest predictor of number of doses remaining was doses dispensed (P < .001). Nineteen percent of families were informed how to dispose of leftover opioid, but only 4% (8 of 211) did so. CONCLUSIONS: Pediatric providers frequently prescribed more opioid than needed to treat pain. This unconsumed opioid may contribute to the epidemic of nonmedical use of prescription opioids. Our findings underscore the need for further research to develop evidence-based opioid prescribing guidelines for physicians treating acute pain in children.

An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions.

BACKGROUND: Prescription errors are among the most common types of iatrogenic errors. Because of a previously reported 82% error rate in handwritten discharge narcotic prescriptions, we developed a computerized, web-based, controlled substance prescription writer that includes weight-based dosing logic and alerts to reduce the error rate to (virtually) zero. Over the past 7 years, >34,000 prescriptions have been created by hospital providers using this platform. We sought to determine the ongoing efficacy of the program in prescription error reduction and the patterns with which providers prescribe controlled substances for children and young adults (ages 0-21 years) at hospital discharge. METHODS: We examined a database of 34,218 controlled substance discharge prescriptions written by our institutional providers from January 1, 2007 to February 14, 2014, for demographic information, including age and weight, type of medication prescribed based on patient age, formulation of dispensed medication, and amount of drug to be dispensed at hospital discharge. In addition, we randomly regenerated 2% (700) of prescriptions based on stored data and analyzed them for errors using previously established error criteria. Weights that were manually entered into the prescription writer by the prescriber were compared with the patient's weight in the hospital's electronic medical record. RESULTS: Patients in the database averaged 9 ± 6.1 (range, 0-21) years of age and 36.7 ± 24.9 (1-195) kg. Regardless of age, the most commonly prescribed opioid was oxycodone (73%), which was prescribed as a single agent uncombined with acetaminophen. Codeine was prescribed to 7% of patients and always in a formulation containing acetaminophen. Liquid formulations were prescribed to 98% of children <6 years of age and to 16% of children >12 years of age (the remaining 84% received tablet formulations). Regardless of opioid prescribed, the amount of liquid dispensed averaged 106 ± 125 (range, 2-3240) mL, and the number of tablets dispensed averaged 51 ± 51 (range, 1-1080). Of the subset of 700 regenerated prescriptions, all were legible (drug, amount dispensed, dose, patient demographics, and provider name) and used best prescribing practice (e.g., no trailing zero after a decimal point, leading zero for doses <1). Twenty-five of the 700 (3.6%) had incorrectly entered weights compared with the most recent weight in the chart. Of these, 14 varied by 10% or less and only 2 varied by >15%. Of these, 1 resulted in underdosing (true weight 80 kg prescribed for a weight of 50 kg) and the other in overdosing (true weight 10 kg prescribed for a weight of 30 kg). CONCLUSIONS: A computerized prescription writer eliminated most but not all the errors common to handwritten prescriptions. Oxycodone has supplanted codeine as the most commonly prescribed oral opioid in current pediatric pain practice and, independent of formulation, is dispensed in large quantities. This study underscores the need for liquid opioid formulations in the pediatric population and, because of their abuse potential, the urgent need to determine how much of the prescribed medication is actually used by patients.

Pain prevalence, intensity, assessment and management in a hospitalized pediatric population.

New research, regulatory guidelines, and practice initiatives have improved pain management in infants, children, and adolescents, but obstacles remain. The aim of this study was to identify the prevalence and demographics of pain, as well as pain management practice patterns in hospitalized children in a tertiary-care university hospital. We prospectively collected data including patient demographics, presence/absence and location of pain, pain intensity, pain assessment documentation, analgesic use, side effects of analgesic therapy, and patient/family satisfaction. Two hundred male (58%) and female, medical and surgical (61%) patients, averaging 9 ± 6.2 years were studied. Pain was common (86%) and often moderate to severe (40%). Surgical patients reported pain more frequently when enrolled than did medical patients (99% vs. 65%). Female gender, age ≥ 5 years, and Caucasian race were all associated with higher mean pain scores. Furthermore, females and Caucasian children consumed more opioids than males and non-Caucasians. Identified obstacles to optimal analgesic management include lack of documented physician pain assessment (<5%), a high prevalence of "as needed" analgesic dosing, frequent opioid-induced side effects (44% nausea and vomiting, 27% pruritus), and patient/family dissatisfaction with pain management (2%-7%). The data demonstrated that despite a concentrated focus on improving pain management over the past decade, pain remains common in hospitalized children. Identification of patient populations and characteristics that predispose to increased pain (e.g., female, Caucasian, postoperative patient) as well as obstacles to analgesic management provide a focus for the development of targeted interventions and research to further improve care.

Efficacy of intravenous patient-controlled analgesia after supratentorial intracranial surgery: a prospective randomized controlled trial. Clinical article.

OBJECT: Opioid administration following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurological examination. Nevertheless, evidence is accumulating that these patients suffer moderate to severe postoperative pain and that this pain is often undertreated. The authors hypothesized that intravenous patient-controlled analgesia (PCA) would safely and more effectively treat postoperative supratentorial craniotomy pain than conventional as needed (PRN) therapy. METHODS: Following a standardized course of general anesthesia, adult patients who underwent elective supratentorial intracranial surgery were randomized in the neurosciences intensive care unit to receive either PRN intravenous fentanyl 25-50 microg every 30 minutes or PCA intravenous fentanyl 0.5 microg/kg every 15 minutes (maximum 4 doses/hour). The authors measured pain (self-reported scale score [0-10]), sedation (Ramsay Sedation Scale score), Glasgow Coma Scale score, fentanyl use, and major adverse events (excessive sedation, respiratory depression, pruritus, nausea, or vomiting) hourly. RESULTS: Sixty-four patients with a mean age of 48 years (range 22-77 years) were randomized to intravenous PCA (29 patients) or PRN fentanyl (35 patients) groups. There were no statistically significant demographic differences between the 2 groups. Patients receiving intravenous PCA had significantly lower pain scores than those receiving intravenous PRN fentanyl (2.53 +/- 1.96 vs 3.62 +/- 2.11 [p = 0.039]) and received significantly more fentanyl than the PRN group (44.1 +/- 34.5 vs 23.6 +/- 23.7 microg/hour [p = 0.007]). There were no differences between the 2 groups regarding the number of patients with adverse events. CONCLUSIONS: Intravenous PCA more effectively treats the pain of supratentorial intracranial surgery than PRN fentanyl, and patients in the former group did not experience any untoward events related to the self-administration of opioids.

Prospective evaluation of pain and analgesic use following major elective intracranial surgery.

OBJECT: Opioid administration after major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect the postoperative neurological examination. The authors conducted a prospective study to evaluate the incidence, severity, and treatment of postoperative pain in patients who underwent major intracranial surgery. METHODS: One hundred eighty-seven patients (77 men and 110 women, mean age 52 +/- 15 years, mean weight 78.1 +/- 19.9 kg) underwent either supratentorial (129 patients) or infratentorial (58 patients) procedures. Sixty-nine percent of the patients reported experiencing moderate to severe pain (> or =4 on a 0-10 scale) during the 1st postoperative day. Pain scores greater than or equal to 4 persisted in 48% on the 2nd postoperative day. Approximately 80% of patients were treated with acetaminophen on the 1st postoperative day, whereas opioids (primarily intravenous fentanyl) were administered to 58%. Compared with patients who underwent supratentorial procedures, those who underwent infratentorial procedures reported more severe pain at rest (mean score 4.9 +/- 2.2 compared with 3.8 +/- 2.6; p = 0.015) and with movement (mean score 6.3 +/- 2.6 compared with 4.5 +/- 2.7; p < 0.001) on the 1st postoperative day. On both the 1st and 2nd postoperative days, patients who underwent infratentorial procedures received greater quantities of opioid (p < or = 0.019) and nonopioid (p < or = 0.013) analgesics than those who underwent supratentorial procedures. Patients' dissatisfaction with analgesic therapy was significantly associated with elevated pain levels on the first 2 postoperative days (p < 0.001). CONCLUSIONS: In contrast to prevailing assumptions, the study findings reveal that most patients undergoing elective major intracranial surgery will experience moderate to severe pain for the first 2 days after surgery and that this pain is often inadequately treated.