Outcomes Presented at the Academic Surgical Congress 2019| Volume 166, ISSUE 2, P172-176, August 2019

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Trends in perioperative opioid and non-opioid utilization during ambulatory surgery in children



      In the midst of our national opioid crisis, recommendations have encouraged judicious stewardship of opioid prescription through the expanded use of non-opioid analgesic medications. This study aims to characterize trends in perioperative pain medication use for children undergoing ambulatory operations.


      A cross-sectional, retrospective review was conducted using the Pediatric Health Information System. Patients younger than 18 years of age who underwent ambulatory surgery during 2010 to 2017 by one of five surgical subspecialties (otolaryngology, general pediatric, plastic or reconstructive, orthopedics, and urology) were included. Medications were identified using Current Procedural Terminology codes based on billing information for 18 commonly used analgesics along with the route of administration during their encounter.


      A total of 1,795,329 patients with a median age of 10 years were identified, of whom 84.3% received an opioid or non-opioid analgesic. Opioid use in the perioperative setting for ambulatory procedures decreased during the study period from 74.9% to 66.9% as a proportion of total analgesic prescriptions. Among opioids commonly used, intravenous morphine decreased the most from 19.8% to 15.4%, and intravenous hydromorphone and oral oxycodone use remained largely unchanged. Conversely, non-opiate medications increased, specifically intravenous ketorolac from 8.4% to 13.6%, and intravenous acetaminophen use increased from 0% to 8.5%. Intravenous acetaminophen use more than doubled between 2013 and 2017 (3.4% to 8.2%) and was accompanied by a decrease in oral acetaminophen use (14.4% to 9.3%).


      Overall, perioperative opioid utilization appears to be decreasing in favor of non-opioid analgesics. Other trends, such as increased intravenous acetaminophen, raise concerns for the cost effectiveness of perioperative analgesia and resource utilization.
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        • Hall M.J.
        • Schwartzman A.
        • Zhang J.
        • Liu X.
        Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010.
        Natl Health Stat Report. 2017; : 1-15
        • Gignoux B.
        • Blanchet M.C.
        • Lanz T.
        • et al.
        Should ambulatory appendectomy become the standard treatment for acute appendicitis?.
        World J Emerg Surg. 2018; 13: 28
        • Jakobsson J.G.
        Pain management in ambulatory surgery—A review.
        Pharmaceuticals (Basel). 2014; 7: 850-865
        • Groenewald C.B.
        • Rabbitts J.A.
        • Schroeder D.R.
        • Harrison T.E.
        Prevalence of moderate-severe pain in hospitalized children.
        Paediatr Anaesth. 2012; 22: 661-668
        • Power N.M.
        • Howard R.F.
        • Wade A.M.
        • Franck L.S.
        Pain and behaviour changes in children following surgery.
        Arch Dis Child. 2012; 97: 879-884
        • Harbaugh C.M.
        • Lee J.S.
        • Hu H.M.
        • McCabe S.E.
        • Voepel-Lewis T.
        • Englesbe M.J.
        • et al.
        Persistent opioid use among pediatric patients after surgery.
        Pediatrics. 2018; 141
        • Krane E.J.
        • Weisman S.J.
        • Walco G.A.
        The national opioid epidemic and the risk of outpatient opioids in children.
        Pediatrics. 2018; 142
        • Nobel T.B.
        • Zaveri S.
        • Khetan P.
        • Divino C.M.
        Temporal trends in opioid prescribing for common general surgical procedures in the opioid crisis era.
        Am J Surg. 2019; 217: 613-617
        • Van Cleve W.C.
        • Grigg E.B.
        Variability in opioid prescribing for children undergoing ambulatory surgery in the United States.
        J Clin Anesth. 2017; 41: 16-20
        • Alam A.
        • Juurlink D.N.
        The prescription opioid epidemic: An overview for anesthesiologists.
        Can J Anaesth. 2016; 63: 61-68
        • Colvin J.D.
        • Hall M.
        • Berry J.G.
        • et al.
        Financial loss for inpatient care of Medicaid-insured children.
        JAMA Pediatr. 2016; 170: 1055-1062
        • McCabe S.E.
        • West B.T.
        • Veliz P.
        • McCabe V.V.
        • Stoddard S.A.
        • Boyd C.J.
        Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015.
        Pediatrics. 2017; 139
        • Bicket M.C.
        • Long J.J.
        • Pronovost P.J.
        • Alexander G.C.
        • Wu C.L.
        Prescription opioid analgesics commonly unused after surgery: A systematic review.
        JAMA Surg. 2017; 152: 1066-1071
        • Bernhardt M.B.
        • Taylor R.S.
        • Hagan J.L.
        • et al.
        Evaluation of opioid prescribing after rescheduling of hydrocodone-containing products.
        Am J Health Syst Pharm. 2017; 74: 2046-2053
        • Tomaszewski D.M.
        • Arbuckle C.
        • Yang S.
        • Linstead E.
        Trends in opioid use in pediatric patients in US emergency departments from 2006 to 2015.
        JAMA Netw Open. 2018; 1: e186161
        • Hollingsworth H.
        • Herndon C.
        The parenteral opioid shortage: Causes and solutions.
        J Opioid Manag. 2018; 14: 81-82
        • Fox E.R.
        • Birt A.
        • James K.B.
        • Kokko H.
        • Salverson S.
        • Soflin D.L.
        ASHP guidelines on managing drug product shortages in hospitals and health systems.
        Am J Health Syst Pharm. 2009; 66: 1399-1406
        • Sinatra R.S.
        • Jahr J.S.
        • Reynolds L.
        • et al.
        Intravenous acetaminophen for pain after major orthopedic surgery: An expanded analysis.
        Pain Pract. 2012; 12: 357-365
        • Song K.
        • Melroy M.J.
        • Whipple O.C.
        Optimizing multimodal analgesia with intravenous acetaminophen and opioids in postoperative bariatric patients.
        Pharmacotherapy. 2014; 34: 14s-21s
        • Rizkalla N.
        • Zane N.R.
        • Prodell J.L.
        • et al.
        Use of intravenous acetaminophen in children for analgesia after spinal fusion surgery: A randomized clinical trial.
        J Pediatr Pharmacol Ther. 2018; 23: 395-404
        • Yung A.
        • Thung A.
        • Tobias J.D.
        Acetaminophen for analgesia following pyloromyotomy: Does the route of administration make a difference?.
        J Pain Res. 2016; 9: 123-127
        • Raiff D.
        • Vaughan C.
        • McGee A.
        Impact of intraoperative acetaminophen administration on postoperative opioid consumption in patients undergoing hip or knee replacement.
        Hosp Pharm. 2014; 49: 1022-1032
        • Wang S.
        • Saha R.
        • Shah N.
        • et al.
        Effect of intravenous acetaminophen on postoperative opioid use in bariatric surgery patients.
        PT. 2015; 40: 847-850
        • Hiller A.
        • Helenius I.
        • Nurmi E.
        • et al.
        Acetaminophen improves analgesia but does not reduce opioid requirement after major spine surgery in children and adolescents.
        Spine. 2012; 37: E1225-E1231
        • Gaither J.R.
        • Leventhal J.M.
        • Ryan S.A.
        • Camenga D.R.
        National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012.
        JAMA Pediatr. 2016; 170: 1195-1201
        • Kane J.M.
        • Colvin J.D.
        • Bartlett A.H.
        • Hall M.
        Opioid-related critical care resource use in us children's hospitals.
        Pediatrics. 2018; 141 ([Epub ahead of print])
        • Kaafarani H.M.A.
        Surgeons as part of the solution: Changing the culture of opioid prescribing.
        Ann Surg. 2018; 267: e48