- POU —
- persistent opioid use
The opioid crisis is currently front-page news.1 The United States leads the world in per capita opioid use as global consumption steadily increases.2,3 The percentage of deaths from opioids, fentanyl, and heroin is rising year after year.3
Harbaugh et al4 used a commercial claims database (Truven Marketscan) to investigate the incidence of persistent opioid use (POU, defined as a filled opioid prescription 3–6 months after an index procedure) in opioid-naïve children undergoing 1 of 13 common operations. The incidence of POU was 4.8% in children who had undergone an operation (versus 0.1% in controls who had not undergone an operation), similar to findings reported in adults.5 The risk factors for POU included female sex, older age, comorbid mental and medical conditions, and a history of previous substance abuse. Nearly 8% of the study group had a diagnosis of depression, anxiety, previous substance abuse, or other mental health disorders, versus 5.2% of controls. Individuals who had undergone colectomy and cholecystectomy had the highest risk of POU. Secondary findings included wide variations in prescribed initial opioid dosages for specific procedures and substantial variation in the procedure-associated rates of POU.
The authors never explained how these 13 diverse procedures were chosen, and the particular operative codes raise questions:
Hypospadias repairs are typically done at 6 to 18 months of age and would be rare in the 13- to 21-year-old population.
Individuals who had undergone epigastric or umbilical hernia repairs (minor procedures also rarely performed in 13–21-year-olds) had prolonged opioid refills at a rate of 5.2%, whereas individuals who had undergone pectus surgery (a painful procedure with a typical 4–5 day hospitalization for pain control) only had a 4.1% incidence of POU. Were the hypospadias and umbilical hernia patients’ prescriptions being filled by their parents and/or siblings for their own use (diversion)?
Two procedures with the highest risk of POU were cholecystectomy and colectomy. The former is often done for chronic abdominal pain attributed to biliary dyskinesia, and a significant percentage of patients have ongoing symptoms not relieved by the procedure. Colectomy is also an uncommon operation in 13- to 21-year-old patients and suggests the possibility of inflammatory bowel disease, often associated with lifelong symptoms and chronic pain.
Only 3 operations (tonsillectomy, arthroscopic knee surgery, and appendectomy) accounted for 80% of the cases. Nearly 44% of the study population were over 17 years of age, also potentially skewing the results.
Conditions (rather than operations) associated with a higher incidence of chronic pain (chronic abdominal pain and biliary dyskinesia, inflammatory bowel disease) may be associated with a higher incidence of persistent POU. Although perhaps logistically impossible, it would be interesting to use a control group with similar underlying diagnoses and compare POU in those who underwent operation with those who did not.
Only 60.5% of children who had 1 of the selected operations actually filled a postoperative opioid prescription. Were the remaining 39.5% (excluded from the study) never given a prescription or just did not fill it? Exclusion of those who refused prescribed pain medication is a potential source of selection bias and could inflate the incidence of POU.
As the authors note, prolonged opioid prescription refills are an imperfect surrogate for POU: underestimating nonprescription use and overestimating inappropriate use in those with chronically painful conditions.
The definition of opioid-naïve excluded prescriptions filled in the month before the index operation, apparently based on the hypothesis that many providers give narcotic pain prescriptions to patients before surgery for convenience, according to 1 of the authors in a previous article.5,6 This practice is atypical in pediatric surgery because of cancelled surgeries, nil per os violations, failure to keep appointments, etc. Limiting opioid-naïve patients to postoperative prescriptions only would have been preferable.
What Can We Learn From This Study?
The rate of long-term (3–6 month) POU in this older pediatric cohort is similar to that found in studies of adults (∼5%);
There was wide variability in the dosage of postoperative opioids prescribed;
Public perception of the risks associated with prescription opioids (compared with street narcotics) is erroneously low; and
If prescription opioids are a “gateway” to narcotic abuse for even a small portion, the personal and societal risks are magnified in children because of their longer lifetime exposure.
The authors are to be congratulated for helping raise awareness of this problem in children who undergo operation. Their plea for providers to develop and use evidence-based strategies for postoperative narcotic prescribing should be heard. Outpatient postoperative pediatric pain management remains an area in which variation and individual physician preferences dominate, and there is a paucity of high quality evidence. Adult studies have demonstrated that information and education can help.7
- Accepted October 10, 2017.
- Address correspondence to Charles L. Snyder, MD, Department of Surgery, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-2439.
- Shear MD,
- Goodnough A
- International Narcotics Control Board
- Katz J
- Harbaugh CM,
- Lee JS,
- Hu HM, et al
- Ciccone TG
- Copyright © 2018 by the American Academy of Pediatrics