Variability in opioid prescribing for children undergoing ambulatory surgery in the United States

Cleve, Wil Van; Grigg, Eliot

doi:10.1016/j.jclinane.2017.05.014

Cited by 53 publications

(33 citation statements)

References 19 publications

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“…The analysis consisted of pairwise comparisons of opioid‐related adverse event occurrence for codeine, oxycodone, and tramadol with that for hydrocodone. Hydrocodone was the reference category because it is the short‐acting opioid most commonly prescribed to adolescents for moderate pain . In univariate comparisons, total exposure to study opioids for cohort members was calculated as the sum of the prescription exposure periods (including both current and recent use) during follow‐up.…”

Section: Methodsmentioning

confidence: 99%

“…Hydrocodone was the reference category because it is the short-acting opioid most commonly prescribed to adolescents for moderate pain. [5][6][7] In univariate comparisons, total exposure to study opioids for cohort members was calculated as the sum of the prescription exposure periods (including both current and recent use) during follow-up. The incidence of opioid-related adverse events was estimated by dividing the number of events by exposure person-years.…”

Section: Comparisonsmentioning

confidence: 99%

“…Although much of the literature focuses on the risks of opioids as a class, important pharmacokinetic and pharmacodynamic differences between individual opioids could affect their relative safety in adolescents. The most frequently prescribed opioids to adolescents for moderate pain related to minor trauma or dental, surgical, or medical procedures are hydrocodone, codeine, oxycodone, and tramadol . Both codeine and tramadol are prodrugs converted to μ‐opioid ligands by the cytochrome P‐450 2D6 (CYP2D6) isoenzyme .…”

Section: Introductionmentioning

confidence: 99%

“…The most frequently prescribed opioids to adolescents for moderate pain related to minor trauma or dental, surgical, or medical procedures are hydrocodone, codeine, oxycodone, and tramadol. [5][6][7][8][9] Both codeine and tramadol are prodrugs converted to μ-opioid ligands by the cytochrome P-450 2D6 (CYP2D6) isoenzyme. 10,11 After case reports of deaths for codeine and tramadol administered following tonsillectomy or adenoidectomy to children and adolescents who were CYP2D6 ultra-rapid metabolizers (UMs), 10,12,13 both opioids ultimately were contraindicated for adolescents 12 to 17 with these procedures, obesity, or serious respiratory conditions.…”

Section: Introductionmentioning

confidence: 99%

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Individual short‐acting opioids and the risk of opioid‐related adverse events in adolescents

Chung

Callahan

Dupont

et al. 2019

Pharmacoepidemiology and Drug

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Purpose Hydrocodone, codeine, oxycodone, and tramadol are frequently prescribed to adolescents for moderate pain related to minor trauma or dental, surgical, or medical procedures. Pharmacokinetic and pharmacodynamic differences between these opioids could affect their relative safety. We aimed to compare occurrence of opioid‐related adverse events in adolescents without cancer or other severe conditions taking hydrocodone, codeine, oxycodone, and tramadol. Methods Retrospective cohort study of 201 940 Tennessee Medicaid enrollees 12 to 17 years of age without cancer, other severe conditions, or evidence of substance abuse with 529 731 filled prescriptions for study opioids. Adverse events were defined as an emergency department visit, hospital admission, or death related to opioid use, confirmed by medical record review. Serious events had opioid‐related escalation of care, hospitalization, or death. Propensity‐score adjusted hazard ratios (HRs) were calculated with hydrocodone as the reference category. Results The incidence of opioid‐related adverse events per 10 000 person‐years of opioid exposure was 97.5 for hydrocodone (127 events/13 026 person‐years), 91.2 for codeine (58/6,359), 229.7 for oxycodone (43/1,872), and 317.7 for tramadol (47/1479). The HRs for tramadol in comparison with hydrocodone for all and serious events were 2.98 (2.03‐4.39) and 2.94 (1.81‐4.75), respectively. Increased risk for tramadol was consistently present when the adverse events were restricted to those with neurologic‐respiratory depression/other symptoms of possible overdose. Conclusion In adolescents without cancer or other severe conditions prescribed short‐acting opioids, the incidence of both all opioid‐related adverse events and more serious events with opioid‐related escalation of care, hospitalization, or death was consistently greater for tramadol than for hydrocodone.

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Section: Methodsmentioning

confidence: 99%

Section: Comparisonsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Individual short‐acting opioids and the risk of opioid‐related adverse events in adolescents

Chung

Callahan

Dupont

et al. 2019

Pharmacoepidemiology and Drug

View full text Add to dashboard Cite

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“…The largest number of patients being seen by the ED in our analysis were for children age 0 to 5 years. Per previous analyses, the perceived increased risk of using opioid analgesics in these younger patients may have prevented providers and parents from aggressively managing pain after surgery . In addition, 183 children >11 years of age were seen for ED revisits, and it might be expected that more children in this age range were prescribed opioid analgesics to manage their postoperative pain.…”

Section: Discussionmentioning

confidence: 99%

Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients

Billings

Manworren

Lavin

et al. 2018

Laryngoscope Investig Oto

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Objective Identify demographic variables related to emergency department (ED) returns, and analgesic administration in the ED for postoperative pain after adenotonsillectomy (T&A). Study Design Pediatric Health Information System (PHIS) database analysis. Methods Forty‐seven children's hospitals included in the PHIS database were queried for all ED visits within 30 days of surgery with a diagnosis of acute postoperative pain (n = 2459) from 2014 to 2015. The subset of postoperative T&A patients (n = 861) was further analyzed for variables associated with return, and for pain management strategies, specifically opioids, employed by the ED. Results Of the 2459 pediatric patients returning to the ED for acute postoperative pain, the largest subset included T&A patients (n = 861, 35%). Patients were seen an average of 4 days (SD 2.4) after their surgery. ED administration of opioids was not associated with gender, race, surgical diagnosis, or ethnicity. The rate of opioid administration by the ED increased with advancing age of the children analyzed ( P = .01). The incidence was also higher for those with commercial versus Medicaid insurance carriers. A total of 204 (23.7%) patients received opioids while in the ED, 439 (51%) received both opioids and non‐opioids, and only 51 (5.9%) received no pain medication. Conclusion T&A patients make up the largest subset of patients returning to the ED for postoperative pain. A total of 74.7% of patients receive opioids, either alone or in combination with non‐opioids, on return to the ED. ED opioid administration was associated with older age of the child and payer, but not with gender, race, surgical diagnosis, or ethnicity. Level of Evidence 4

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Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US

Keane,

Ourshalimian,

Lakshmanan

et al. 2024

JAMA Netw Open

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ImportanceHigh-risk infants, defined as newborns with substantial neonatal-perinatal morbidities, often undergo multiple procedures and require prolonged intubation, resulting in extended opioid exposure that is associated with poor outcomes. Understanding variation in opioid prescribing can inform quality improvement and best-practice initiatives.ObjectiveTo examine regional and institutional variation in opioid prescribing, including short- and long-acting agents, in high-risk hospitalized infants.Design, Setting, and ParticipantsThis retrospective cohort study assessed high-risk infants younger than 1 year from January 1, 2016, to December 31, 2022, at 47 children’s hospitals participating in the Pediatric Health Information System (PHIS). The cohort was stratified by US Census region (Northeast, South, Midwest, and West). Variation in cumulative days of opioid exposure and methadone treatment was examined among institutions using a hierarchical generalized linear model. High-risk infants were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and other abdominal surgery. Infants with neonatal opioid withdrawal syndrome, in utero substance exposure, or malignant tumors were excluded.ExposureAny opioid exposure and methadone treatment.Main Outcomes and MeasuresRegional and institutional variations in opioid exposure.ResultsOverall, 132 658 high-risk infants were identified (median [IQR] gestational age, 34 [28-38] weeks; 54.5% male). Prematurity occurred in 30.3%, and 55.3% underwent surgery. During hospitalization, 76.5% of high-risk infants were exposed to opioids and 7.9% received methadone. Median (IQR) length of any opioid exposure was 5 (2-12) cumulative days, and median (IQR) length of methadone treatment was 19 (7-46) cumulative days. There was significant hospital-level variation in opioid and methadone exposure and cumulative days of exposure within each US region. The computed intraclass correlation coefficient estimated that 16% of the variability in overall opioid prescribing and 20% of the variability in methadone treatment was attributed to the individual hospital.Conclusions and RelevanceIn this retrospective cohort study of high-risk hospitalized infants, institution-level variation in overall opioid exposure and methadone treatment persisted across the US. These findings highlight the need for standardization of opioid prescribing in this vulnerable population.

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Variability in opioid prescribing for children undergoing ambulatory surgery in the United States

Cited by 53 publications

References 19 publications

Individual short‐acting opioids and the risk of opioid‐related adverse events in adolescents

Individual short‐acting opioids and the risk of opioid‐related adverse events in adolescents

Pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients

Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US

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