Changing culture to reduce opioid prescriptions for children undergoing surgery

New effort responds to concerns about opioid overdose, misuse and side effects in kids; Expert shares 8 things parents and pediatric surgeons should know

2:23 PM

Author | Beata Mostafavi

doctor talking and parent standing by child in hospital bed
Justine Ross, Michigan Medicine

One of the first surgeries Karen Cooper, M.D., learned to perform during residency nearly 25 years ago was a tonsillectomy in children.

The common procedure came with a painful recovery, and back then, surgeons didn’t think twice about prescribing opioids for pain relief.

But over time, Cooper noticed red flags with the practice.

Kids using opioids after surgery had side effects like nausea, vomiting and constipation and some families called for refills long after pain should have been resolved. She’d also read about rare events of pediatric deaths at home following tonsillectomy that had been linked to opioids.

More than two decades later, Cooper, now a pediatric otolaryngologist at University of Michigan Health C.S. Mott Children’s Hospital, is part of a team leading efforts to change the culture in her field to decrease opioid use in pediatric patients. 

Cooper and colleagues are expanding the work of University of Michigan-based Opioid Prescribing Engagement Network, or OPEN, to the pediatric population. OPEN takes a preventive approach to the opioid epidemic through research, engagement and evidence-based actions, such as tailoring prescription recommendations and addressing over-prescribing by surgeons.

“When we counsel families, we talk about risks of bleeding after tonsillectomy, which happens one out of 30 to 40 times. But many of us don’t talk to them about the risk of their postoperative opioid prescription, which has a higher likelihood of a long-term effect on their family’s health,” Cooper said. “As surgeons, we want to alleviate suffering, especially when it comes to children,” she added. “But it’s our responsibility to make the same practice changes for pediatrics as we’ve done for adults by finding strategies that address pain management without contributing to the opioid epidemic that has devasted communities.”

The work is funded by a three-year, half a million dollar grant from the Michigan Health Endowment Fund and has involved several initiatives targeting both health providers and families. These include development of a website and toolkits for both health professionals who treat post-operative pain and pediatric patients experiencing pain after surgery.

Cooper answers more questions about the mission of the OPEN pediatric initiative and what’s most important for families and providers to know.

1.  Young kids are vulnerable to opioid overdose

Cooper: Since children aren’t usually dispensing the medication to themselves, they are particularly vulnerable to overdose risk, especially if an opioid is given to a child to help them sleep.

This is especially significant in children with obstructive sleep-disordered breathing, obstructive sleep apnea and obesity. These children are already prone to a life-threatening breathing disorder known as respiratory depression that can be worsened with opioids.

2.  Many providers aren’t aware of proper dosing guidelines

Cooper: Another child-specific opioid risk relates to the way opioids are dosed in kids.  While adults typically receive a standard dose, children weighing less than 110 pounds receive a dose based on their weight. However, this is most accurate when children fall into a healthy body-mass index weight category since opioids have a relatively small volume of distribution and aren’t well-absorbed by fat.  

But if opioids are dosed the same way in children who have a BMI higher than the 95th percentile for their age (consistent with a diagnosis of obesity), they are at greater risk for overdose and respiratory complications. 

As surgeons, we want to alleviate suffering, especially when it comes to children. But it’s our responsibility to make the same practice changes for pediatrics as we’ve done for adults.” Karen Cooper, M.D.

Our data shows that many providers aren’t aware of this information, and the electronic order prescribing of opioids doesn’t alert them that they should adjust dosing because of a child’s specific BMI.

3.  Families aren’t always safely storing or disposing unused opioids

Cooper: Opioids are risky for anyone who uses them or has access to them when they are kept in the home.  Anyone can have side effects, and even when used for a short time, kids are at risk for dependence, tolerance and misuse as well as continued use.

Studies suggest that many families aren’t disposing of unused opioids or storing them safely. This increases risks of diversion and opioid use disorder, especially for older kids and teens. To quote other experts, “leaving an opioid left in an unsecured location in the home has the same risk level as a loaded gun left in an unlocked medicine cabinet.” 

4.  It’s not uncommon for children and adolescents to receive excessive or unnecessary opioid prescriptions

Cooper: We are fortunate to learn from our own U-M experts who have researched the prevalence of opioid prescribing to children and teens. Studies by OPEN, for example, show that one out of 20 adolescents continues to receive a prescription for an opioid three months after surgery, far past the time post-surgical pain should have resolved. 

Other studies reinforce data indicating widespread overprescribing to the pediatric population. We also have a post-operative pain task force at Mott that has focused on research identifying problematic trends in opioid prescribing after surgery.

5.  Parents and caregivers whose children receive opioid prescriptions should know the dos and don’ts

Cooper: If your child is undergoing surgery, take the time to educate yourself about opioid risks and alternatives. Use as little as possible for as short a time as possible.  Don’t use them at bedtime or to help your child sleep.  Start with non-opioid medications and non-medication first and continue to use these even if your child is taking opioids.  Dispose of the opioid as soon as surgery-related pain has resolved. 

6.  The pediatric OPEN group provides evidence-based resources to help guide both families and providers

Cooper: The work OPEN does with children is different than with adults because the patient care team has a relationship both with the patient as well as their family or caregiver who is often the one administering medications.  

Our website houses resources for families about expected pain and pain management following common surgical procedures in children as well as information about safe disposal of unused medications. We provide evidence-based prescribing recommendations for surgeons and providers, such as the use of nonsteroidal anti-inflammatory drugs or NSAIDs in the post-operative pain management regimen to decrease opioid prescribing.

Our guidelines are driven by outcome surveys from more than 1,000 families with children or adolescents who underwent surgical procedures most likely to lead to opioid prescriptions, including tonsillectomies and dental procedures.

We also got consensus on best practices to manage pain after surgery from a multidisciplinary task force involving surgeons, anesthesiologists, nurses, child life representatives and pharmacists. This not only helped us develop a physician toolkit but also make updates at our own hospital. For example, University of Michigan Health discharge orders now include Tylenol and Motrin as first-line medications to manage pain following pediatric surgeries.

7.  Changing the culture around opioid prescribing to kids will take time

Cooper: It’s hard to change the culture because we’re concerned about our patients suffering.  We performed the procedure that led to the patient’s pain, and we want to provide strong pain relief that makes recovery easier on them and their families.

There’s also a desire to provide pain medications in a timely and convenient matter. Liquid oxycodone – the most common opioid prescribed after surgery in younger children or those undergoing procedures where there may be difficulty swallowing, such as tonsillectomy – often isn’t available at pharmacies outside of the hospital. Providers may be concerned that if families, many who travel a long distance for surgery, don’t fill a prescription while they’re at the hospital, it will be more difficult to do so if they need it later.    

Some in the field have also expressed concerns that post-surgery phone calls to our clinics about pain will increase and result in dissatisfied patients and families as well as nurses, residents and others on the clinical care team. Finally, it can be hard to change habits, especially when surgeons don’t see ongoing use in their patients because their relationship is episodic and confined to the surgical experience.

8.  Pediatric surgeons and providers are key to decreasing opioid use in children

Cooper: We played a role in the opioid epidemic and we have a responsibility to help end it. My message to peer surgeons: Change your practice to discuss the risks of opioids with patients and their families and educate them about non-opioid medications and non-medication alternatives. If you’re prescribing an opioid after surgery, do so based on the guidelines at OPEN – which emphasize tailoring prescriptions for actual use – and educate families about safe storage and disposal.

For me personally, learning more about the risk of opioid overdose after surgery in young children and seeing some of the frightening statistics motivated my deeper involvement.  Because I had been a part of the problem for the past several decades, I felt a mandate to be part of the solution.

More Articles About: Drug Abuse and Misuse Post Operative and Recovery Pharmacy Opioids Medication Guidelines substance use disorder Tonsils Health Care Delivery, Policy and Economics Pediatric Health Conditions Children's Health
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