February 28, 2018 - Children and adolescents undergoing surgery can be swept up in the ongoing opioid epidemic, according to a review and update in the Journal of Pediatric Orthopaedics, official journal of the Pediatric Orthopaedic Society of North America (POSNA). The journal is published by Wolters Kluwer.
"The magnitude of the problem of prescription opioid use by children and teenagers is overwhelming," according to the article by Ellen Raney, MD, of Shriners Hospitals for Children, Portland, Ore., and colleagues. They present finding from a POSNA survey of opioid prescribing by pediatric orthopaedic surgeons, along with recommended strategies to reduce opioid prescribing and potential misuse among children and adolescents.
Specialists Urged to Respond to High Rates of Opioid Use by Children and Teens
Dr. Raney and coauthors trace the roots of the opioid epidemic to policies of the 1980s and 1990s advocating opioid treatment of pain as a "moral imperative." Dependence or addiction to opioid medications may occur as quickly as two months in about one-third of people. According to one estimate, 16 percent of the US population has an opioid addiction--outnumbering those with heart disease, diabetes, and cancer.
"Though it receives less attention, the dilemma in the pediatric and teenage population is no less dire," Dr. Raney comments. "Like most doctors who work to provide the best care for all patients, we were stunned by the extent and origin of the problem as research became available."
In one study, nearly 13 percent of high school seniors reported nonmedical use of prescription opioids. Most of these initially had a legitimate prescription, but used their leftover medications recreationally. Overall, nearly one-fourth of US high school seniors had some exposure to prescription opioids. A study of seventh- and eighth-graders found a five percent prevalence of nonmedical prescription opioid use.
The National Poison Data System reported that 60 percent of pediatric exposures to prescription opioids, reported as poisonings, were in children up to five years old, and 30 percent in teenagers. Most teenage opioid deaths were from intentional opioid use, whereas children under six were exposed unintentionally to medications around the home.
Dr. Raney and colleagues report findings from a 2016 survey of POSNA member surgeons regarding opioid prescribing. Three-fourths of responding surgeons said they made pain management decisions for their patients, rather than involving a pain specialist. Medication decisions were based mainly on "anecdotal experience," rather than on the limited evidence or guidelines currently available.
The survey findings raise concern that decisions about opioid prescribing may be made without research or understanding of the best management strategies. Some of the prescribing practices could lead to surplus of medications that could be diverted to nonmedical or recreational use.
Dr. Raney and colleagues outline strategies that pediatric orthopaedic surgeons can follow to minimize the impact of the opioid epidemic in children and teens undergoing surgery. First steps include education and standardized prescribing practices, including appropriate plans for disposal of unused pills.
Other strategies include changing patient expectations for postoperative pain control, along with legislation and other initiatives to shift prescribing practices. The authors outline specific strategies before, during, and after surgery to reduce opioid prescribing and nonmedical use. They write, "The need to manage our patients' pain appropriately should be safely balanced against the potential harm of drug diversion to both the individual and society at large."
Dr. Raney and colleagues conclude, "We as pediatric orthopaedists can make a difference by educating ourselves and our trainees, improving our prescribing patterns, and encouraging patients to utilize nonopioid and nonpharmacologic modalities to decrease pain." This year's POSNA Annual Meeting, to be held May 9-12 in Austin, Texas, will include a special symposium on the opioid epidemic and strategies for pediatric orthopaedic patients.