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What’s New in the Patient Safety World

December 2020

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery



The first-ever guidelines for opioid prescribing in children after surgery were just published in JAMA Surgery (Kelley-Quon 2020). The guidelines were developed by expert panel review and opinion. One particular concern was that opioid prescribing in adolescents may lead to opioid misuse and abuse, potentially leading to opioid addiction. They also recognize that many opioid-free analgesic regimens may be used successfully in children.


The guideline emphasizes use of enteral non-opioid regimens as first line therapy for pain post-operatively but also recommends use of perioperative intravenous non-opioids like ketorolac and acetaminophen.


The guidelines also endorse the FDA guidelines regarding limited use of codeine and tramadol for children younger than 18 years. Our extensive columns on the dangers of codeine (and tramadol) use in children are listed below.


The guideline emphasizes that caregivers and children be educated about expectations and methods of pain management both before the day of surgery and again perioperatively. Pain management messaging should be consistent from all members of the perioperative team. Education should be in plain, nonmedical language, regardless of health literacy level, and delivered in the language most familiar to the family.


If opioids are prescribed, perioperative education should include instruction regarding possible adverse drug events, seriousness of adverse drug events, and what to do if they occur.


It is also recommended to educate caregivers and older children to store opioids in a secure location and properly dispose of unused medication. The guideline recommends health care entities caring for pediatric patients should consider providing infrastructure and means for safe opioid disposal. That infrastructure might include a local drug disposal box in the health care facility or home disposal mechanisms, such as drug deactivation compounds.


Disposal of unused opioids is such an important issue, yet options have been poorly understood. The FDA recommends that such unused opioids be returned to the healthcare facility (or other designated site) but, if that is not possible, they be flushed down the toilet. The FDA has a section on disposal of unused medicines (FDA 2020), including a list of medicines recommended for disposal by flushing, which includes opioids. We’ve always been concerned that flushing results in opioids eventually reaching a water supply where animals or humans will become exposed.


A relatively new approach has been to provide bags of activated charcoal to patients at discharge to be used for inactivation and disposal of unused opioids. Brummett et al (Brummett 2019) found that receiving an activated charcoal bag for in-home disposal of unused opioids was associated with a 3.8-fold increase in self-reported disposal among adults who underwent elective surgical procedure, compared with receiving usual care. It resulted in less flushing and less inappropriate garbage disposal. An abstract recently presented at the annual meeting of the American Society of Regional Anesthesia and Pain Medicine by Yi et al (abstract 830) reported on a small prospective study of providing education and a disposal bag to patients at discharge after surgery. Prior to the intervention, 52% did not dispose of their narcotics. After the education and disposal bag were given, this rate increased to 93.5% (Vlessides 2020). The FDA does have an outstanding “Safe Opioid Disposal - Remove the Risk Outreach Toolkit” that includes a host of posters, public service announcements, and videos on the importance of proper disposal of opioids but has not yet added anything regarding the activated charcoal disposal bags as far as we can see.


It’s important to recognize that non-opioid pain regimens can adequately and more safety control pain after surgery in most cases. But sometimes opioids may be needed. Many studies have shown that we tend to prescribe far more opioid pills than needed when patients are discharged post-surgery. Even with efforts to limit such over-prescribing (at the hospital level, specialty society level, or state health department level), it is inevitable that some patients will be left with opioids that are no longer needed. It’s critical that we not only educate patients and caregivers on proper disposal but give them the tools or infrastructure needed to accomplish safe disposal.



Some of our previous columns on opioid safety issues in children:







Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg 2020; Published online November 11, 2020



FDA (US Food and Drug Administration). Disposal of Unused Medicines: What You Should Know. FDA 2020



FDA (US Food and Drug Administration). List of medicines recommended for disposal by flushing. Updated: April 2018



Brummett CM, Steiger R, Englesbe M, et al. Effect of an Activated Charcoal Bag on Disposal of Unused Opioids After an Outpatient Surgical Procedure: A Randomized Clinical Trial. JAMA Surg 2019; 154(6): 558-561



Vlessides M. Education and Easy Disposal Option Lower Opioid Supply. Anesthesiology News 2020; November 10, 2020



FDA (US Food and Drug Administration). Safe Opioid Disposal - Remove the Risk Outreach Toolkit; Updated 11/1/2020






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