An Evidence-Based Guideline Supporting Restricted Opioid Prescription after Pediatric Appendectomy

Freedman-Weiss, Mollie; Chiu, Alexander S.; Worhunsky, David J.; Manchisi, Alefteria; Torres-Maldonado, Isabel; Sagnella, Lisa; Caty, Michael G.; Cowles, Robert A.; Ozgediz, Doruk; Christison‐Lagay, Emily R.; Solomon, Daniel; Stitelman, David H.

doi:10.1016/j.jpedsurg.2019.09.063

Cited by 26 publications

(14 citation statements)

References 36 publications

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“…11,19,20,27 Investigators have substantially reduced opioid quantities in perioperative prescriptions for adult patients by developing procedure-specific prescribing guidelines on the basis of data on patient-reported postoperative opioid consumption. 28,29 Similar efforts have begun in some pediatric institutions 30 but should be more f Includes internists in sports medicine and geriatrics and physicians dually boarded in internal medicine and anesthesiology, family medicine, pediatrics, and preventive medicine. g Includes nonpain medicine anesthesiology and pain medicine physicians from anesthesiology, neurology, physical medicine and/or rehabilitation, and psychiatry.…”

Section: Discussionmentioning

confidence: 99%

Opioid Prescribing to US Children and Young Adults in 2019

et al. 2021

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BACKGROUND: Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years. METHODS:We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with $1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by $1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the $95th percentile.RESULTS: Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had $1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of $50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by $1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions.CONCLUSIONS: Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broadbased initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.

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Section: Discussionmentioning

confidence: 99%

Opioid Prescribing to US Children and Young Adults in 2019

et al. 2021

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“…In the pediatric population, it has been shown that narcotic prescribing practices after appendectomy is variable [12,13] and most patients do not require narcotic medication for adequate postoperative pain control [14][15][16]. Within our hospital system, a quality improvement project was enacted within the pediatric population with implementation of a perioperative multimodal pain guidelines and monthly feedback reports to surgeons detailing their prescription behavior.…”

Section: Discussionmentioning

confidence: 99%

A multi-institutional approach for decreasing narcotic prescriptions after laparoscopic appendectomy

et al. 2022

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Background Appendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control. With the opioid epidemic and a demonstrated link between excessive narcotic prescriptions paving the way to dependence and addiction, it is more important than ever to decrease the circulation of these medications. We hypothesized that a perioperative, multimodal analgesia strategy coupled with monthly feedback reports comparing hospitals narcotic prescribing habits would decrease, and in some cases eliminate, the use of outpatient narcotics in adults after laparoscopic appendectomy. Methods A quality improvement project was initiated to provide monthly feedback to surgeons on narcotic prescribing habits after adult laparoscopic appendectomies. A multi-hospital database was created to include adult patients that were diagnosed with acute appendicitis, treated with laparoscopic appendectomy, and discharged within 48 h of surgery. The database provided information regarding the number of narcotic doses prescribed on discharge. Participating hospitals selected a site champion who distributed monthly prescribing reports. A protocol was created and distributed to participating sites that provided a guideline for preoperative and postoperative pain medication management. The intervention period was 10/1/2019-3/31/2020. We utilized the preceding year's data (October 1, 2018-September 30, 2019) as the pre-intervention control group. We also compared results between local and distant sites to see if personal connection to surgeons influenced the results. Results A total of 1785 appendectomies were performed during the study period at participating hospitals. The average number of prescribed narcotics decreased from 23.6 doses during the control period to 14.2 during the intervention (p < 0.001). There was no change in the number of total narcotic prescriptions (8.9 vs 7.9%, p = 0.52). Overall, the average number of narcotics prescribed decreased by 40% with similar decrease in average prescribed narcotics for local and distant hospitals, respectively (47.7% vs 42.1%). Average narcotic dose during the first 2 months of intervention at the local hospitals was 9.7 and 11.1 for the last 2 months of intervention (p = 0.69). Average narcotic dose during the first 2 months of intervention at the distant hospitals was 19.5 and 13.4 for the last 2 months of intervention (p = 0.005). Conclusion A multimodal pain regimen combined with a monthly narcotic prescription report provided to prescribers decreases the average number of narcotic prescriptions after laparoscopic appendectomy. Local sites demonstrated immediate decrease in narcotic utilization compared to distant sites whose change occurred more gradually.

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“…At present, there are few evidence-based guidelines delineating appropriate postoperative prescribing of postoperative opioids, with some studies noting the need to balance adequate pain management with an appropriate duration of opioid treatment 11,12 and others indicating that adequate analgesia may be provided without any opioid administration in some settings. 13 Despite the ongoing opioid crisis, postoperative opioid prescribing practices vary widely from institution to institution, surgeon to surgeon, and case to case. 10 This study examined the effect that demographic and temporal factors, particularly the day of the week and the postoperative day at the time of discharge, might have on the amount of postoperative opioids prescribed by general surgeons.…”

Section: Discussionmentioning

confidence: 99%