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Whats 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 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
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% .
Its 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. Its 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:
- September 2012 FDA Warning on Codeine Use in Children
Following Tonsillectomy
- March 2013 Further Warning on Codeine in Children Following
Tonsillectomy
- May 2014 Pediatric Codeine Prescriptions in the
ER
- November 2015 FDA
Safety Communication on Tramadol in Children
- January 2016 FDA
Gets Even Tougher on Codeine in Kids
- October 2016 Another
Codeine Warning for Children
- May 2017 FDA
Finally Restricts Codeine in Kids; Tramadol, Too
- February 2018 FDA
Warning on Cough Meds
References:
https://jamanetwork.com/journals/jamasurgery/article-abstract/2772855
https://jamanetwork.com/journals/jamasurgery/fullarticle/2729448
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