Our demonstrates significant variability in the rate of opioid prescribing by surgical subspecialty, as well as variability in the amount of opioid prescribed per patient. This results corroborates previous documentation that even at a single institution postoperative analgesic prescriptions vary widely. Inconsistency in opioid prescription across surgical services and for specific procedure types may be multifactorial in etiology. While differences in types of surgeries and underlying pathologies can lead to varied degrees of postoperative pain, surgical prescribing culture may also drive these findings [19]. Surgical services may currently determine their discharge opioid prescription practices based on convention rather than evidence or protocols, as supported by a study showing disparate discharge opioid prescriptions in laparoscopic appendectomies on adolescents performed by adult versus pediatric general surgeons at the same institution [20].
Most pediatric surgeries performed in the USA are ambulatory and, by design, are expected to result in minimal and manageable postoperative pain [21]. Despite this, surgeons may overprescribe opioids because they are concerned about adequate postoperative analgesia or because there are currently no standard guidelines for appropriate analgesic dosing regimens for pediatric patients. Some institutions have started publishing evidence-based, procedure-specific guidelines for adult surgical patients, but these have not yet been widely disseminated for pediatric populations [22].
Pediatric discharge prescribing could be optimized by establishing procedure-specific opioid and non-opioid regimens, considering whether opioids are necessary for some surgeries or for some patients, and ensuring adequate dosing of analgesics to avoid uncontrolled postoperative pain. Our study supports the need to closely evaluate and tailor postoperative pain medication regimens by surgery type as part of a multi-pronged approach [23] to optimize opioid stewardship as well as postsurgical analgesia and safety for pediatric patients. “Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.”
Our study highlights an important contributor to the opioid epidemic in the pediatric population. While the overall rate of postoperative opioid prescriptions was low for pediatric ambulatory surgery patients; among those who received opioids, the rate of unused opioids was still high. We observed this trend across many different specialties and procedures, highlighting a concerning pattern of postoperative opioid overprescription. Thus, despite awareness of the risks of opioids in children and adolescents, postoperative opioid prescribing leading to a reservoir of unused opioid medication in the community still occurred in pediatric ambulatory surgery patients.
Surgeons in our study were also more likely to prescribe opioids to older children, those who underwent longer surgeries, and those who lived further away from the hospital. Older age remained a clinically significant predictor of opioid prescription in multivariable analysis.
While national organizations recommend judicious use of opioids in infants, they also endorse conservative opioid prescription in older children and adolescents [23]. Adolescents with no prior history of drug use are particularly at risk for future opioid dependence or misuse, theoretically because the exposure to postoperative opioids in a legitimized and controlled setting may downplay its potential risks [3]. Adolescent neurodevelopment in executive function and inhibitory control is not fully mature and may also contribute to these patients’ initial risk-taking behavior with prescribed opioids, which may then develop into dependence and future misuse [24].
While longer case length and distance from the hospital did were not significant predictors of opioid prescription in multivariable analysis, these factors may still be important considerations in surgeons’ prescribing decisions. Surgeons may anticipate more pain after longer surgeries and may therefore be more likely to prescribe opioids on discharge [8]. They may also be concerned about inadequate analgesia in patients who live further away and have difficulty returning to the hospital for assessment or a prescription. Importantly, however, case length and distance from the hospital were not significant predictors of using opioids in our analyses, and therefore may not be useful considerations when prescribing postoperative medications.
Surgeons were less likely to prescribe opioids to patients with governmental insurance than those with private insurance, and those with governmental insurance who were prescribed opioids were less likely to use them. Children receiving insurance benefits through governmental programs such as Medicaid are disproportionately children of color and—by virtue of their enrollment—are economically disadvantaged [25]. Our dataset did not include information about race/ethnicity, cultural background, socioeconomic status, or primary language and therefore does not provide insight into the underlying drivers of these findings; future research should investigate further to understand these disparities in both prescription and use of opioids.
Limitations
This study was based on a telephone survey, which by nature is dependent on self-report and subject to recall bias and participants’ subjective interpretation. We corroborated patients’ responses to the first question of the survey by identifying discharge opioid prescriptions in our electronic medical records; approximately 9% of patients who reported being prescribed an opioid did not have a recorded discharge opioid prescription. These patients may have filled the opioid prescription in advance of the procedure instead of on the day of discharge, or they may have used opioids available through other means at home; however, this suggests that our unused opioid prescription rate may be overestimated. Our study was conducted at a single academic hospital in San Francisco, and findings may therefore not be generalizable to all hospitals in the USA, particularly private hospitals or those in less urban settings. Our dataset did not include information on race/ethnicity, specific medical comorbidities, or prescription of non-opioid adjuncts, all of which may influence opioid prescription and/or need after surgery. Finally, it is possible that there have been changes in prescription patterns, postoperative medication compliance, and insurance status since the time this study was initially conducted. Despite these limitations, our findings show that opioids are being prescribed at a rate and amount that is often higher than patients’ use, offering an opportunity for optimizing postoperative opioid prescription patterns in pediatric ambulatory surgery patients.