New guidelines lay out risks associated with post-op opioid RX

Health care workers who care for children post-surgery need to understand the risks associated with opioids, maximize non-opioid pain management, and educate families about appropriate — and safe — opioid use.

Those are the recommendations of an interdisciplinary team of experts based on a review of the current literature regarding opioid use and risks unique to pediatric populations.

These guidelines, published in JAMA Surgery, were developed by the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee, along with a multidisciplinary team composed of experts in opioid management who have been involved in organizing opioid initiatives at their home institutions. The group included representatives from the American College of Surgeons (ACS) Education Committee, the American Academy of Pediatrics Section on Surgery, pediatric anesthesia, pediatric nursing, general surgery residency, pediatric surgery physician assistants, and addiction science.

Lorraine I. Kelley-Quon, MD, MSHS, Division of Pediatric Surgery, Children’s Hospital of Los Angeles, and colleagues, screened almost 15,000 articles for inclusion, and selected 217 for qualitative analysis. Based on these they generated 20 guidelines, which were endorsed by orthopedic, otolaryngology, and urologic pediatric specialists, the American Pediatric Surgical Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the ACS Board of Regents.

Six of the guidelines related to “opioid misuse, heroin use, diversion, and conversion to long-term use.” The panel recommended that healthcare professionals recognize that a significant percentage of adolescents with access to opioids will misuse them, develop dependence or opioid use disorders, and potentially graduate to heroin use. In addition, healthcare professionals need to understand that prescriptions are the most common source of opioids for adolescents, that many adolescents prescribed opioids will divert them, and that adolescents who are prescribed opioids after surgery are more likely to receive future opioid prescriptions.

Eight of the guidelines pertain to efforts to limit opioid use and maximize nonopioid pain management options For example, opioid-free postoperative analgesia is recommended for many pediatric operations, such as inguinal hernia repair, umbilical/epigastric hernia repair, pyloromyotomy, soft tissue excision, pectus bar removal, central line placement, myringotomy, circumcision or hypospadias repair, and meatotomy, although it is possible to use them for operations such as laparoscopic appendectomies and tonsillectomy.

Other recommendations concerning perioperative nonopioid regimens included:

  • The nonopioid option or options as first-line treatment when discharge analgesics are necessary.
  • The use of perioperative enteral nonopioid analgesic use when clinically appropriate.
  • The use of perioperative intravenous nonopioid medications, such as ketorolac, as part of an opioid-sparing regimen.
  • Targeted use of perioperative regional or neuraxial anesthesia techniques.
  • The limited use of codeine and tramadol for children younger than 18 years.

The remaining six recommendations relate to patient and family education. The panel recommended that both caregivers and children receive education about expectations regarding pain and pain management before and after the day of surgery. Messaging regarding pain management should be consistent, and pain management should be tailored to the caregiver’s and child’s needs. And if opioids are prescribed education should include instructions regarding potential adverse drug events, as well as the need to store drugs in secure locations and to dispose of unused medications properly.

“The present review underscores the need for further qualitative and quantitative research on educational interventions for families to optimize understanding of perioperative pain management and appropriate opioid use, storage, and disposal,” the authors observed, adding that more work is needed to optimize the delivery – and retention of – pain management education.

In a commentary accompanying the study, Adam C. Alder, MD, and Dai H. Chung, MD, both of the University of Texas Southwestern Medical Center, Dallas, noted that Kelley-Quon and her colleagues took a data-driven approach in coming up with their recommendations. “Their emphasis on the data provided a much-needed basis for individual surgeons and institutions to set up prescribing guidelines and perioperative opioid administration,” wrote Alder and Chung.

Alder and Chung did add that they were concerned that even with these recommendations, some health providers will continue to follow pain management regimens based on experience and current practice. Specifically, they noted that the authors’ list of recommended and possibly opioid-free procedures “may allow many to continue routine prescription of opioids and suggest that a liberal approach to opioid prescription is not out of line with recommendations to use nonopioid medications as an initial step.”

Without specific recommendations to limit opioid use, Alder and Chung warned, “many will continue a laissez-faire approach to their prescribing practices.”

  1. A panel of experts on pain management has issued guidelines related to the use of postoperative opioid prescribing for children and adolescents.

  2. Recognition of the risks of misuse and dependence associated with prescription opioid use, optimization of perioperative pain management with nonopioid alternatives, and patient and family education regarding pain management and safe opioid use practices, were outlined in the guidelines.

Michael Bassett, Contributing Writer, BreakingMED™

Kelley-Quon reported grants from Southern California Clinical and Translational Science Institute and the National Center for Advancing Translational Sciences during the conduct of the study.

Cat ID: 138

Topic ID: 85,138,254,138,192,144,925,159