Fig. 1 Narcotic prescribing and use after pediatric orthopaedic surgeries
Courtesy of S. Clifton Willimon, MD, FAAOS; Children’s Healthcare of Atlanta

AAOS Now

Published 9/2/2021
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Ariel DeMaio

More than Half of Opioids Prescribed to Young Patients After Surgery Go Unused

Adolescents undergoing orthopaedic surgery are commonly prescribed opioid medications for postoperative pain management, but few pediatric patients actually consume the full amount of tablets or liquid doses prescribed, according to a study conducted at Children’s Healthcare of Atlanta. Despite this discrepancy, 91 percent of patients reported being satisfied or very satisfied with their pain control.

S. Clifton Willimon, MD, FAAOS, from Children’s Healthcare of Atlanta, will present these findings today.

“Physicians must counsel patients and families about postoperative pain expectations and appropriate medication use,” Dr. Willimon told AAOS Now Daily Edition. “This study provides the framework for the development of educational resources regarding prescribing and use of pain medications for healthcare providers, patients, and caregivers.”

This prospective study enrolled 342 patients (age range, 5–20 years) who were undergoing one of seven common orthopaedic surgeries (posterior spinal fusion for adolescent idiopathic scoliosis [PSF AIS], epiphysiodesis, closed reduction and percutaneous pinning of supracondylar humerus fracture [CRPP SCH], anterior cruciate ligament reconstruction, knee arthroscopy, shoulder arthroscopy for anterior labral repair, and hip arthroscopy for femoroacetabular impingement). All procedures were performed by 11 surgeons at a single institution.

Patients received either hydrocodone-acetaminophen 5 to 325 mg tablets or hydrocodone-acetaminophen 7.5 to 325 mg/15 mL elixir for postoperative pain control. Patients and their families completed a medication logbook to track all doses of pain medication and associated pain scores. They also were asked to describe satisfaction with pain control, medication side effects, and whether they received instructions on medication use from a medical provider.

A total of 9,867 tablets and liquid doses of narcotic pain medication were prescribed, with an average of 29 tablets or liquid doses per patient. Nearly all patients (98 percent) filled their prescriptions.

At the end of follow-up, only 4,351 tablets and liquid doses of the narcotic medication, or 44 percent of the total prescribed, were consumed. Only 32 patients (9.4 percent) consumed all of their prescribed medications. Patients who were undergoing PSF AIS and shoulder arthroscopy were the most likely to use 100 percent of their prescribed medications. See Fig. 1 for a breakdown of narcotic prescriptions and consumption by procedure.

Duration of narcotic use was longer than anticipated, at 5.4 days, with a wide standard deviation (4.7 ± 3 days).

Multivariable linear regression analysis showed no significant differences in the amounts of narcotics consumed between sexes or ethnicities. Non-steroidal anti-inflammatory (NSAID) use independently predicted less narcotic use, with an average of 5.1 fewer narcotic tablets consumed among patients who took NSAIDs (P = 0.003). Receipt of education about when and how to take narcotic medication also significantly decreased duration of narcotic use, highlighting the importance of educating patients and families regarding the appropriate indications for these medications and methods to decrease overall use, the authors reported.

Even with so many opioids going unused, patient satisfaction was high, with 91 percent reporting being “satisfied” or “very satisfied” with their pain control. Notably, female gender and use of all the prescribed narcotics were associated with decreased overall satisfaction, compared to satisfaction levels in the entire cohort.

When asked whether these results suggest that providers are prescribing too many or too few opioids, Dr. Willimon described the balance between under- and overprescribing. “Accounting for the variability in medication consumption by individual patients, and inability for providers to call in prescriptions for narcotics, too narrow of a prescribing range may result in inadequate medication and patient and family dissatisfaction,” he said. “Based on the results of our study, our institutional recommendations for prescribing are the sum of each procedure’s mean plus two standard deviations.”

In the this study’s cohort, using that calculation would have resulted in a decrease in 1,445 prescribed narcotic tablets (15 percent) and a decrease in 1,447 remaining pills (26 percent).

Dr. Willimon suggested that electronic prescribing ability may have affected opioid prescription patterns. “Since narcotic prescriptions can’t be ‘called in’ to the pharmacy, we suspect providers tended to prescribe more generously to avoid patients having to travel back to the hospital or clinic to pick up another prescription, particularly when patients live hours away,” he said. “E-prescribing allows narcotic prescribing in a secure manner, so this should help doctors prescribe smaller numbers of narcotic doses, such as the mean number of tablets we found needed in our study, and additional tablets could be e-prescribed if deemed necessary, based on the doctor’s assessment.”

The study will be presented as Paper 489 today at 8:40 a.m. in Room 32.

Dr. Willimon’s coauthors of “Opioid Use in Children and Adolescents following Common Orthopaedic Surgeries” are Asahi Murata, BS, and Crystal A. Perkins, MD.

Ariel DeMaio is the managing editor of AAOS Now.