Provider education leads to sustained reduction in pediatric opioid prescribing after surgery

https://doi.org/10.1016/j.jpedsurg.2021.08.004Get rights and content

Highlights

  • Over prescription of opioids leads to addiction, overdose deaths, and diversion.

  • There is significant variation in prescribing patterns for pediatric surgeons.

  • Provider education can decrease opioid prescribing after umbilical hernia repair.

  • The prescription reduction persists a year after intervention.

Abstract

Background

The majority of opioid overdose admissions in pediatric patients are associated with prescription opioids. Post-operative prescriptions are an addressable source of opioids in the household. This study aims to assess for sustained reduction in opioid prescribing after implementation of provider-based education at nine centers.

Methods

Opioid prescribing information was collected for pediatric patients undergoing umbilical hernia repair at nine centers between December 2018 and January 2019, one year after the start of an education intervention. This was compared to prescribing patterns in the immediate pre- and post-intervention periods at each of the nine centers.

Results

In the current study period, 29/127 (22.8%) patients received opioid prescriptions (median 8 doses) following surgery. There were no medication refills, emergency department returns or readmissions related to the procedure. There was sustained reduction in opioid prescribing compared to pre-intervention (22.8% vs 75.8% of patients, p<0.001, Fig. (1). Five centers showed statistically significant improvement and the other four demonstrated decreased prescribing, though not statistically significant.

Conclusions

Our multicenter study demonstrates sustained reduction in opioid prescribing after pediatric umbilical hernia repair after a provider-based educational intervention. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of pediatric surgical procedures.

Levels of evidence

(treatment study)-level 3

Introduction

Between 2006 and 2017, deaths related to prescription opioids increased by an annual average of 2% [1]. The rate of deaths involving synthetic opioids (fentanyl, fentanyl analogs, and tramadol) increased by 45% between 2016 and 2017, from 6.2 to 9.0 per 100,000 [2]. In 2017, prescription opioid medications claimed the lives of approximately 17,000 people in the United States [1]. Overall, opioids accounted for almost 68% of drug overdose deaths. Opioid related poisonings resulted in nearly 200,000 emergency department visits in the United States in 2016, a rate of 62 visits per 100,000 population. Young adults continue to remain at high risk, with 5.5% reporting misuse of prescription pain medications within the past year [1].

This epidemic is affecting both adult and pediatric patients. The rate of opioid overdoses in pediatric patients tripled between 2000 and 2012, during which 84% of pediatric opioid overdose admissions were owing to prescription opioids [3]. Furthermore, it has also been shown that pediatric surgical patients have a higher risk of persistent opioid use compared with non-surgical controls [4]. This emphasizes the importance of opioid stewardship among physicians and surgeons who serve as a potential gateway to opioid addiction. Unfortunately, the amount of prescription opioids that pediatric providers currently supply to patients and the community is unnecessarily high. A recent study in 2018 found that for 7 of 9 procedures analyzed, pediatric patients consumed less than half of the prescribed opioids after discharge and 64% kept the remaining prescription opioids in their home [5]. An analysis of the National Survey on Drug Use and Health (NSDUH) from 2015 to 2016 found that among those misusing opioids, 55.7% obtained them from friends or relatives. This type of diversion was also the most common source for adolescents (33.5%) and young adults (41.4%) [6]. Another recent study found that among US high school seniors surveyed, the most common source of non-medical use prescription drugs including opioids that are “given free from friends” (53.7%), “bought from a friend” (38.0%), or “from their own prior prescription” (29.5%) [7].

There is currently significant variation in opioid prescribing and limited guidelines to assist pediatric surgeons in their choice of dosage or duration of therapy after various operations [8,9]. In pediatric urology, for instance, 48% of providers reported always prescribing opioids to patients undergoing routine procedures such as orchiopexy, hydrocele repair, and circumcision, while 14% reported never prescribing opioids for these cases. Furthermore, only 16% of the providers felt that patients take the majority of opioids prescribed [10]. Overprescribing and prescriber variation are targets to safely address the oversupply of prescription opioids in the community. In pediatric urologic surgery, a reduction in prescribed opioids by 50% did not lead to a significant increase in post-operative pain [11]. Similar reductions may be achievable for other common pediatric surgical procedures without negative consequences to the patient.

Key initiatives for reducing opioid prescribing must include provider education. We previously reported short term results for a nine center study, in which a brief thirty to sixty minute presentation to providers was associated with a significant decrease in opioid prescribing after pediatric umbilical hernia repair [12]. In the present study, we aim to determine if the decrease in opioid prescriptions after an educational intervention persists in the long-term.

Section snippets

Intervention

Between January and August of 2018, a thirty to sixty minute slide presentation was given at nine children's medical centers across the United States, representing 74 pediatric surgeons. The presentation was targeted to pediatric surgeons, advanced practice providers, residents, and fellows. Key items presented included: (1) data demonstrating the significance of the opioid epidemic, (2) the current large variation in opioid prescribing practices, (3) the effectiveness of multimodal pain

Results

One year after the start of the initiative, 127 new patients were identified ranging from 8 to 40 patients per site with a median age of 6 years (range 0.14–15 years) and a median umbilical hernia size of 1.3 cm. There were 29 patients (22.8%) prescribed opioids with a median and adjusted mean of 8 and 8.17 doses respectively (0.18 adjusted mean morphine equivalents/kg/dose), ranging from 0% to 60% of patients being prescribed opioids at each center. No patients received a new opioid

Discussion

Recent literature in general surgery suggests that provider education can significantly reduce opioid prescribing after various operations, without increasing pain-related emergency department visits [13]. In early data from our study that was previously published, we also found that similar reductions could be achieved for pediatric surgical patients undergoing umbilical hernia repair. A brief educational intervention to pediatric surgical providers was associated with a significant reduction

Conclusions

Our multicenter study demonstrates sustained and reduced opioid prescribing after pediatric umbilical hernia repair one year after a provider-based educational intervention. Though prescription patterns between sites remain variable, these results suggest continued improvements may be expected. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of children's surgical procedures.

Dear Dr. Holcomb, July 25, 2021

We are grateful

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

None.

Acknowledgments

This work was supported in part by the University of Chicago Bucksbaum Institute for Clinical Excellence

Cited by (3)

View full text