Decreased Prescribing of Postoperative Opioids in Pediatric ACL Reconstruction: Treatment Trends at a Single Center

Background: Anterior cruciate ligament (ACL) injury is common in the pediatric population. Pain control after ACL reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Pain management practices are believed to have evolved in recent years to limit unnecessary exposure to risks associated with opioid use in this vulnerable population. Purpose: To describe trends in postoperative opioid prescribing and assess factors including obtaining consent for opioid prescribing for minors that may have mitigated excessive prescription of opioids. Study Design: Cohort study; Level of evidence, 3. Methods: This is a retrospective review of a consecutive series of pediatric patients (<18 years) undergoing primary ACLR within an urban academic hospital system over a 5-year period (2014-2018). The study period included the gradual introduction of preoperative consenting for opioid use in minors as mandated by state law in 2016. Patient characteristics, surgical details, presence of a signed consent form to prescribe opioid medications, prescribed postoperative medications, prescriber, and indicators of inadequate pain control were collected. Univariate and multivariate analyses were performed to determine factors associated with reduced postoperative opioid prescribing. Results: This study included 687 patients with a mean age of 15.1 ± 1.9 years, with less than one-third of patients having preoperative consent forms to prescribe opioid medications. Postoperative prescribing trends demonstrated a decline in the number of opioid doses provided and increased utilization of nonopioid medications. Patients who received preoperative opioid counseling and signed a consent form were prescribed fewer opioids and had a smaller number of unscheduled contacts for poorly controlled pain. Univariate analyses identified multiple predictors of the number of opioid doses prescribed postoperatively. Obtaining preoperative consent to prescribe opioids and ambulatory surgery center location were found to be independent predictors of prescribed doses in the multivariate analysis. Conclusion: The quantity of opioid medication prescribed for pain management after pediatric ACLR at our institution has declined in recent years. This appears to be, in part, related to state-mandated preoperative counseling about opioid use, signing of a consent form by the parent(s) or guardian(s) to prescribe opioids to minors, and encouragement toward the use of nonopioid medications when possible. Preoperative opioid use discussions in the pediatric population may be useful in reducing opioid overprescription and utilization in this population.

Provider Bias in Prescribing Opioid Analgesics: An Analysis of Emergency Department Electronic Medical Records

Background: Physicians do not prescribe opioid analgesics for pain treatment equally across groups, and such disparities may pose significant public health concerns. While research suggests that institutional constraints and cultural stereotypes influence doctors’ treatment of pain, prior quantitative evidence is mixed. The objective of this secondary analysis is therefore to clarify which institutional constraints and patient demographics truly bias provider prescribing of opioid analgesics.Methods: We used electronic medical record data from an emergency department of a large U.S hospital during years 2008-2014. We ran multi-level logistic regression models to estimate factors associated with providing an opioid prescription during a given visit while controlling for ICD-9 diagnosis and between-patient heterogeneity.Results: A total of 180,829 patient visits among 65,513 unique patients were recorded during the period of analysis. Overall, providers were significantly less likely to prescribe opioids to the same individual patient when the visit occurred during higher rates of emergency department crowding, earlier times of day, earlier times of the week, later years, and when the patient had received fewer previous opioid prescriptions. Across all patients, providers were significantly more likely to prescribe opioids to patients who were middle-aged, white, and married. We found no bias towards women and no interaction effects between race and crowding or between race and gender.Conclusions: Providers tend to undertreat pain during constrained diagnostic situations and undertreat pain for patients from high-risk and marginalized demographic groups. Harm from previous treatment mistakes are likely to accumulate through informing future treatment decisions.

What are Future Pain Physicians Learning? A Survey of Opioid Prescribing Practices Among US Pain Fellowship Programs

Background: Pain physicians have long been seen as subspecialists that commonly prescribe opioid medications, but the reality exists that primary care, oncologists, and surgical subspecialists find themselves embroiled in these clinical decisions just as frequently. It is a reasonable hope that pain physicians emerge as leaders in navigating these muddy waters, and the most important time to engrave practice standards is during clinical training. Objectives: It was our hope to survey Accreditation Council for Graduate Medical Education (ACGME) pain fellowship programs throughout the United States in regard to practice behaviors for opioid prescribing in chronic noncancer pain (CNCP), and to assess what future pain physicians are learning during their training. Study Design: We developed a succinct, 8-question survey that attempted to gauge several aspects of opioid prescribing practices for CNCP. A survey was prepared in electronic format and e-mailed to each program director or chair of every ACGME accredited pain program in the United States. Methods: Our results were anonymously collected and percentage of response to each question was presented in bar graph format. The survey was prepared and initially sent out in November 2017 and intermittently redistributed through April 2018. Results: Of the 117 surveys sent through Survey Monkey, 42 responses were returned and collected, 39 fully completed surveys, and 3 partial completions, an estimate of roughly one-third of US ACGME pain fellowship programs. Limitations: Completion of our survey was voluntary, roughly 35% of ACGME programs submitted a response. Conclusions: Data displayed in collected responses illustrate that although there is variance in opioid prescribing practices for CNCP, many programs are limiting what they use opioids for and have substantial nonopioid pharmacologic and or interventional aspects to their practice. Future pain physicians throughout the country are learning diverse methods of pain management, with opioids being only a part of their toolbox. Key words: Opioids, ACGME, pain management fellowship, guidelines, teaching

Developing a Culture of Opioid Stewardship

The goal of opioid stewardship is to provide public health practitioners and health care professionals with the education and tools they need to appropriately prescribe opioid medications to patients for whom an opioid is indicated and to reduce the overall supply of unused opioid medications that might be diverted and used by individuals other than the intended patient. In this chapter, the Pennsylvania Department of Health’s experience with developing a comprehensive opioid stewardship approach illustrates that creating a statewide culture of opioid stewardship is a process requiring active involvement of health care professionals, provider and patient groups, law enforcement agencies, academic institutions and large health systems, state policymakers and politicians, and the general public. By analyzing Pennsylvania’s experience of building a culture of opioid stewardship, other states can learn how to foster opioid stewardship to ensure its effective spread across the nation.

Clinician opioid prescribing practices and patient utilization of prescribed opioids in pediatrics

Objective: Little is known regarding clinician prescribing of opioid medications and of patient use of prescribed opioid medications in pediatrics. The authors sought to learn more about pediatric clinician opioid prescribing practices and patient utilization and disposal of prescribed opioids.Design: Cross-sectional, observational study.Setting: Tertiary care pediatric healthcare center.Participants: Pediatric clinicians who prescribe opioid medications and parents of children prescribed an opioid medication.Main Outcome Measures: Clinicians were surveyed about opioid prescribing practices for acute pain management in children, and parents were asked about utilization and disposal of prescribed opioids.Results: Most clinician respondents (64 percent) reported prescribing opioid medications to manage acute pain. The typical length of opioid prescriptions was limited to 7 days (93 percent). Parents reported a high prevalence of leftover opioid medications (86 percent). Most (59 percent) did not dispose of the remaining medication.Conclusions: Targets for intervention to reduce unnecessary opioid exposure in youth are identified.

Buprenorphine: A review

A significant breakthrough in the treatment of opioid addiction occurred with the passage of the Data Addiction Treatment Act of 2000 (DATA 2000),1 signed into law by President Clinton, which allowed physicians for the first time in more than eight decades to prescribe opioid medications for the treatment of opioid addiction in the normal course of their practice. Two years later, on October 8, 2002, Suboxone (Buprenorphine/Naloxone) and Subutex (Buprenorphine) received FDA approval for the treatment of opioid addiction. Prior to DATA 2000, opioid maintenance treatment was available through highly regulated methadone clinics. This article discusses opioid addiction in the United States today and the principles of buprenorphine therapy.