Overprescribing and Undereducating: a Survey of Pre- and Postoperative Pain Protocols for Pediatric Anterior Cruciate Ligament Surgery

Abstract

Purpose: To establish a better understanding of the variations in pain management protocols and prescribing patterns for pediatric patients undergoing anterior cruciate ligament (ACL) reconstruction or repair. Methods: A 20-question multiple-choice survey was distributed to 3 professional orthopaedic societies to assess the pre-emptive and postoperative pain management prescribing patterns for pediatric patients undergoing ACL reconstruction or repair. Clinical agreement (defined as agreement between >80% of participants) and general agreement (defined as agreement between >60% of participants) were calculated based on responses as previously reported. Results: Clinical agreement was observed among the 68 respondents in use of a single shot nerve block before induction of anesthesia versus continuous use when a peripheral nerve block was used, "always" counseling patients on postoperative pain control, the prescribing of opioids postoperatively, and a lack of change in postoperative protocol when concomitant meniscal repair or meniscectomy was performed. General agreement was observed in the use of a peripheral nerve block, some pre-emptive analgesia practices, and the lack of counseling patients with regard to disposal of unused opioid pain medication postoperatively. Opioids were prescribed by 88% of participants postoperatively, with 48% prescribing 11 to 19 pills and 15% prescribing 20 pills. Conclusions: While pain management practices before and following ACL reconstruction and repair in the pediatric population remain varied, opioids are frequently prescribed postoperatively with many providers neglecting to provide instruction on excess opioid disposal. Clinical Relevance: ACL reconstruction and repair is becoming increasingly common in the pediatric population. Clinical guidelines that establish pre-emptive and postoperative pain-control protocols should be considered to determine safe and optimal pain control throughout the duration of care while minimizing opioid prescribing and consumption.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction

“…The main reason for not instructing patients was being uninformed about the proper ways of disposing of opioid pain medication. This finding is in line with a recent survey that was published by Perry et al 30 that reported 63% of physicians did not counsel patients on how to dispose of unconsumed opioid tablets. This demonstrates a gap in providing education about safe prescribing practices.…”

Does Liposomal Bupivacaine Injectable Suspension Peripheral Nerve Block Further Aid in Decreasing At-home Narcotic Utilization in Children and Adolescents After Anterior Cruciate Ligament Reconstruction

“…One study surveying the prescribing practices of opioids to pediatric patients after ACLR demonstrated that 48% of surgeons prescribed 11 to 19 opioid tablets and 25% prescribed 6 to 10 tablets. 12 Pain medication prescribing practices have also been demonstrated as undertreating pain in Black and Hispanic patients with White patients being more likely to receive opioid prescriptions than other racial and ethnic groups. 13,14 Beck et al 15 found the median number of hydrocodone/acetaminophen 5/325 mg consumed by their adolescent patients after ALCR with or without meniscal treatment was less than half of what was prescribed (17/40 tablets).…”

“…Comparatively, these current results maintain 72% of patients did not require postoperative opioids in the SPNB+B group, and 93% of patients did not consume narcotics in the SPNB+BL group. One study surveying the prescribing practices of opioids to pediatric patients after ACLR demonstrated that 48% of surgeons prescribed 11 to 19 opioid tablets and 25% prescribed 6 to 10 tablets 12 . Pain medication prescribing practices have also been demonstrated as undertreating pain in Black and Hispanic patients with White patients being more likely to receive opioid prescriptions than other racial and ethnic groups 13,14 .…”

Standardized Opioid Counseling Is Underperformed Before and After Anterior Cruciate Ligament Reconstruction

“… 1 Studies have also shown that up to 88% of orthopaedic surgeons prescribe opioids after ACLR to the pediatric population. 12 It is interesting to note that many studies have reinforced the notion that these high quantities of opioids provide no added benefit for pain outcomes after ACLR. A study by Hartwell et al.…”