Previous research indicates that prescription patterns for opioids after surgery in children and adolescents may be associated with long-term use and abuse.²

“Pediatric patients have developing brains that are uniquely vulnerable to addiction, and we need to learn to treat their pain safely without putting them at additional risk for opioid misuse,” said principal investigator Kathryn (Kate) DelPizzo, MD, an anesthesiologist at HSS.

It is therefore critical for clinicians to understand risk factors for opioid dependence in this vulnerable population, and to develop strategies to prevent long-term opioid use.

Dr. DelPizzo and colleagues examined insurance claims from Truven Health Marketscan data from patients under the age of 21 who underwent inpatient or outpatient surgery from 2013 to 2017. The primary outcome examined was persistent opioid use after surgery, defined as one or more additional filled opioid prescriptions between 90 and 180 days post-surgery.

Out of more than 3.7 million patients, about 9% (N=345,523) filled at least one opioid prescription within six months after surgery, and 0.3% (N=11,334) developed ongoing opioid use.

Several risk factors were identified for persistent opioid use: older age, female sex, earlier year of undergoing surgery (e.g., 2013 versus 2014 through 2017), higher burden of comorbidities, previous use of antidepressants, residence outside of the Northeastern United States, having undergone an inpatient or a musculoskeletal procedure (versus general surgery or other specialties), and previous opioid use.

“This data gives an indication that providers may be able to use a patient's baseline characteristics to predict which children and adolescents are most at risk for trouble with opioids during the postsurgical period,” Dr. DelPizzo noted.

HSS is committed to patient safety and being a leader in effective pain management. Its Controlled Substances Task Force continues to make strides in patient education and safe prescribing.

In addition to this study, HSS is ramping up further research on opioids with the help of a $3 million grant from the Starr Foundation. “Future research should explore what practical methods can be put into place to identify these at-risk pediatric patients and how to streamline protocols to help prevent long-term opioid dependence in these patients,” Dr. DelPizzo concluded.

References

1. Kathryn DelPizzo MD, Haoyan Zhong MPA, Lauren A. Wilson MPH, Hannah N. Ladenhauf MD, Jiabin Liu MD PhD, Jashvant Poeran MD PhD, Stavros G. Memtsoudis MD PhD MBA FCCP. “Factors Associated With Long-term Opioid Use in Pediatric Surgical Patients.” Presented at: 46th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), May 13-15, 2021; Orlando, FL.

2. Harbaugh CM, Lee JS, Hu HM, et al. Persistent opioid use among pediatric patients after surgery. Pediatrics 2018; 141:e185838.

HSS Researchers Find Duloxetine May Reduce Opioid Use and Improve Pain Management After Total Knee Replacement

• Anesthesiologist Jacques Ya Deau, MD, PhD and colleagues investigated using duloxetine after surgery to reduce pain and opioid use. They found that duloxetine, given on the day of surgery and once daily for 14 days afterwards, reduced opioid use by about 30%. Patients receiving duloxetine were also more satisfied with their pain management.

Study Identifies Risk Factors for Pediatric Opioid Dependence After Surgery

• Anesthesiologist Kathryn (Kate) DelPizzo, MD and colleagues identified risk factors for persistent opioid use after surgery in pediatric patients. Understanding risk factors for opioid dependence could help develop strategies to prevent long-term opioid use in this vulnerable population.

Knowledge Gaps on Opioid Use and Pain Relief After Surgery Offer Opportunities for Improving Patient Education

• Anesthesiologist Bradley Lee, MD and colleagues identified gaps in patient knowledge about pain management and opioid use before total hip replacement, including misconceptions about how much pain relief to expect from opioids after surgery, how to use multiple modes of pain relief, and proper opioid storage and disposal. Improving patient education about opioids and pain management could lead to improvements in pain control and functional outcomes after surgery.

Interim Study Results Suggest Oral Tranexamic Acid (TXA) Is Equally Effective as Intravenous TXA in Preventing Blood Loss in Joint Replacement Surgery

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA and colleagues examined the efficacy and safety of oral TXA for joint replacement surgery. Using oral TXA versus intravenous TXA could translate to improvements in efficiency, cost and safety.

HSS Study Examines Hip Fracture Patient Characteristics and Outcomes Pre- and Post-COVID-19 Outbreak

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA and colleagues sought to compare characteristics and outcomes of hip fracture patients admitted during the COVID-19 outbreak to patients admitted before the outbreak. They also examined characteristics and outcomes of hip fracture patients with and without the virus.

Recent research has shown an increase in ambulatory pediatric orthopedic surgery in the United States.^2,3 Although there is evidence suggesting that regional anesthesia benefits this population, this topic remains understudied.

"We undertook this large-scale study with the notion that regional anesthesia benefits children. However, we were aware that it is underutilized in this population and wanted to identify factors that were associated with its use," said anesthesiologist Kate DelPizzo, MD. "Overall, children have been less likely to receive regional anesthesia than adults, but that has changed due to widespread use of ultrasound and due to more formal training practices on regional anesthesia. At our institution, the majority of children receive regional anesthesia, but we are aware that we practice at a highly specialized place, so we wanted to find out what other institutions around the state are doing."

To examine this subject, as well as what factors might be associated with decreased use of regional anesthesia, Dr. DelPizzo and colleagues at HSS analyzed a large population-based cohort of patients below age 21.

Researchers identified pediatric patients who underwent anterior cruciate ligament repair or reconstruction, knee arthroscopy, or shoulder arthroscopy. Patient and healthcare system information was analyzed to determine whether regional anesthesia was used, including spinal anesthesia, epidural anesthesia, caudal anesthesia, and other peripheral nerve blocks.

Out of 87,273 pediatric patients undergoing anterior cruciate ligament repair or reconstruction (n=28,226), shoulder arthroscopy (n=18,155) or knee arthroscopy (n=40,892), only 11,404 (13.07%) received regional anesthesia as the primary anesthetic for their surgery.

"Our main conclusions are that the majority of patients under 18 having ambulatory (same-day release) surgery are not receiving regional anesthesia. The older you are, the higher your chance receiving regional anesthesia, which makes sense because it is always easier to perform regional anesthesia on an older child," said Dr. DelPizzo.

Dr. DelPizzo and her colleagues also found that Hispanic race and Medicaid insurance were associated with decreased odds of receiving regional anesthesia. "Disparities in healthcare are known to exist but remain relatively understudied in the field of anesthesia. This represents a problem, especially when we know that a certain intervention like regional anesthesia is associated with better outcomes but does not get applied equally to all groups of the population."

"It is difficult to draw conclusions as to why we see what we see from this type of data, but it forces us to ask questions and design studies that could determine that a mechanism," Dr. DelPizzo said.

The results from this study have potentially wide-reaching takeaways for parents, clinicians, and policymakers.

"Regional anesthesia used to be something that was only performed at large medical centers where there is a focus on teaching and where there are more resources available, but over the past decade, an increasing number of clinicians have learned how to perform these techniques," said Dr. DelPizzo. "However, even with that knowledge, they need to be in an environment with support systems enabling them to do so. Policymakers and administrators should provide an environment that facilitates this type of practice. The more successful a hospital is in providing an infrastructure, the more likely it is for patients to receive regional anesthesia."

"Patients are also becoming savvier and may ask for regional anesthesia, and we as physicians should be able to deliver it no matter where they live and who they are," Dr. DelPizzo added.

Parents of patients whose children require surgery that are amenable to regional anesthesia can also take away some tips from this research.

"If patients are able to choose where to have surgery, they should do some research to see if regional anesthesia is offered," she said.

References

1. Kathryn DelPizzo MD, Megan Fiasconaro MS, Jiabin Liu MD PhD, Lauren A. Wilson MPH, Janis Bekeris MD, Jashvant Poeran MD PhD, Stavros G. Memtsoudis MD PhD. “Low socioeconomic status and minority race decrease the odds of the provision of regional anesthesia in pediatric patients undergoing common ambulatory orthopedic procedures.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.

2. Dodwell ER, LaMont LE, Green DW, Pan TJ, Marx RG, Lyman S. 20 years of pediatric anterior cruciate ligament reconstruction in new york state. The American Journal of Sports Medicine. 2014;42(3):675-680.

3. Tepolt F, Feldman L, Kocher M. Trends in pediatric ACL reconstruction from the PHIS database. Journal of Pediatric Orthopaedics. 2018;38(9):e494.

HSS Training in Ghana Expands Physician Knowledge and Use of Regional Anesthesia During Surgery

• Anesthesiologists Swetha R. Pakala, MD, and Mark A. Brouillette, MD, presented research showing that the Global Health Initiative increased physician knowledge, clinical skills and use of peripheral nerve blocks for extremity surgeries at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana.

HSS Provides New Recommendations for Anesthesia Use During Total Joint Replacement

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA, and colleagues who participated in a year-long consensus project published their recommendations for the type of anesthesia that should be used during total hip replacement and total knee replacement.

Minority, Low Socioeconomic Status Pediatric Patients Getting Ambulatory/Sports-Related Surgeries Are Less Likely to Receive Regional Anesthesia

• Anesthesiologist Kate DelPizzo, MD, found that in New York state, younger pediatric patients, as well as minorities and those with low socioeconomic status, are less likely to receive regional anesthesia during ambulatory surgeries. She emphasized that this disparity in care must be addressed.

Cautious Approach Recommended for Determining Same-Day Discharge After Total Joint Replacement

• Although the overall risk for complications is low, anesthesiologist Jiabin Liu, MD, PhD, found that same-day discharge after total joint replacement may increase the risk for cardiac and pulmonary complications. He urges a measured approach and case-by-case consideration in recommending same-day discharge for patients.