Pediatric Post‐Tonsillectomy Opioid Prescribing Practices

Abstract

Objective: To evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding.Methods: Retrospective chart review of pre-and post-intervention in pediatric post-tonsillectomy patients, 0-18 years old (n = 1486). Order sets were installed with age-specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time-balanced pre-and post-intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed.Results: Discharge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg [95% CI, 0.092-0.099] vs. 0.079 [95% CI, 0.076-0.083], P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 [95% CI,.1] to 20.3 [95% CI, 19.1-21.5], P < .001). Patients <7 years old prescribed opioids remained rare in pre-and post-intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post-intervention group showed an increase in readmissions for post-tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post-intervention group after stratification by age.Conclusion: Utilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post-tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention.

Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

“…After provider education and implementing our standardized dosing protocol at BCSC, the average number of oxycodone doses per patient decreased significantly and there were no significant differences in rates of refill requests, 7‐day ED visits, or readmissions. The effects of reducing and eliminating opiates in posttonsillectomy patients have been studied, and our results are consistent with previous reports 4,18‐26 . Cordray et al implemented a similar opiate‐sparing protocol and studied its effects on both prescribing habits and outcomes in 1817 tonsillectomy patients.…”

“…The effects of reducing and eliminating opiates in posttonsillectomy patients have been studied, and our results are consistent with previous reports. 4,[18][19][20][21][22][23][24][25][26] Cordray et al implemented a similar opiate-sparing protocol and studied its effects on both prescribing habits and outcomes in 1817 tonsillectomy patients. Poststandardization, the average opioid dose per prescription decreased by 16.7 doses (P < .001), interpatient variance decreased significantly (P < .001), and there was no significant increase in the incidence of return to the system for pain or reduced oral intake.…”

“…However, a standard clinical protocol for the number of opioid doses prescribed following tonsillectomy does not currently exist at most institutions 3,4 . As a result, there is significant variability in posttonsillectomy opioid prescribing practices among otolaryngologists 4‐7 . Over the past several decades, increasing awareness about the risks of opioids including nausea, respiratory depression, drug‐drug interactions, and abuse potential, have spurred efforts to ensure the safety and appropriateness of postsurgical opioid prescriptions in pediatric populations 3,8 .…”

“…Opioids are commonly utilized as part of a multimodal pain regimen in conjunction with steroids, nonsteroidal anti‐inflammatory drugs (NSAIDs), and acetaminophen. However, a standard clinical protocol for the number of opioid doses prescribed following tonsillectomy does not currently exist at most institutions 3,4 . As a result, there is significant variability in posttonsillectomy opioid prescribing practices among otolaryngologists 4‐7 .…”

Impact of state legislation and institutional protocols on opioid prescribing practices following pediatric tonsillectomy

“…In addition to legislation, multiple studies have shown that the implementation of institutional protocols, including electronic health record order sets can reduce variability in opioid prescriptions. Two publications reported this specifically for pediatric tonsillectomy 37,38 . It has been well described that high variation in perioperative prescribing is a major contributor to the supply side of the opioid pool 9 .…”