In This Era of Opioid Abuse, Don’t Forget to Provide Pain Relief

Author: Michael Vlessides

Anesthesiology News

Pediatric patients are certainly not immune to the ravages of the opioid epidemic. This reality should motivate medical professionals to examine their practice and prescribing patterns. However, a Maryland clinician reminded anesthesiologists they need to remember that providing pain relief is a vital part of their professional responsibilities.

“When I started my pediatric anesthesiology fellowship, we were at the cusp of important changes in the way we managed pain in children,” said Constance L. Monitto, MD, an assistant professor of anesthesiology and critical care medicine at Johns Hopkins Medicine, in Baltimore. “Pain was bad, and opioids were considered a reliable tool against it.

“Well, here we are, almost 30 years later, and we’re in the midst of an opioid epidemic,” Dr. Monitto continued. “And the genesis of this epidemic is being blamed, in large part, on the more liberal opioid dosing strategies that started back in the 1990s.”

As she noted at the 2018 annual meeting of the Society for Pediatric Anesthesia, however, current prescribing patterns also may be playing a role in opioid diversion. “Most pediatric anesthesiologists are probably dispensing or prescribing opioids to children on a daily basis, either in the OR or to treat postoperative pain,” she said.

As noted in an article by Dr. Monitto and her colleagues (Anesth Analg 2017;125[6]:2113-2122), children may be sent home with far more opioids than they need. In the study, the parents of 343 pediatric inpatients were questioned within 48 hours and 10 to 14 days after hospital discharge to determine the amount of opioids prescribed and consumed; the duration of treatment; and the disposition of unconsumed opioids.

Among other things, the study found that 58% (95% CI, 54%-63%) of dispensed doses were not consumed. Moreover, the strongest predictor of the number of doses remaining was the number of doses dispensed (P<0.001).

“Not surprisingly,” Dr. Monitto said, “we found that most of these families had leftover opioid in their house. Only a few of them had been told what to do with their leftover opioids, and even fewer—4%, in fact—actually disposed of the opioid.”

Opioids Are a Problem in the Home

Physicians themselves are not above this alarming pattern when they become patients. “If you’re given an opioid prescription, you’re going to keep it in case you need it down the road,” said Peter J. Davis, MD, a professor of anesthesiology and perioperative medicine and pediatrics as well as the Joseph H. Marcy Endowed Chair in Pediatric Anesthesiology at UPMC Children’s Hospital of Pittsburgh. “And if you have adolescents in the house, there’s additional concerns because of the high rate of adolescent behavior that can involve some sort of drug experimentation.”

Although anesthesiologists may not necessarily be the ones writing postoperative prescriptions for their pediatric patients, they can play an important role when it comes to educating patients about the risks associated with opioid use and misuse.

“For one thing, we should be helping people understand better places for them to dispose of their opioid if they’re uncomfortable doing it at home,” Dr. Monitto said. “When we started doing this research, pharmacies were very rarely offering these opportunities. Now they’re doing it regularly.” Some institutions also have installed on-site lockboxes to encourage patients to dispose of unused opioids when they return for follow-up visits.

Education comes in many forms, however, and Dr. Monitto believes anesthesiologists also can be an important source of information for their surgical colleagues. For example, her department has worked with the institution’s pediatric orthopedic surgeons to develop postoperative prescribing guidelines. “The goal is to try and encourage multimodal analgesia whenever possible,” she explained. “We’ve also recommended numbers of doses for different procedures, which are significantly less than what has been prescribed in the past.”

‘Just Say No’ Is Not the Answer

Despite these efforts to curb opioid abuse, Dr. Monitto was clear that effectively treating pain must still be the hallmark of every anesthesiologist’s practice. “I am not advocating for us to give up adequately treating our patients’ pain,” she said. “But I am very concerned that if we don’t take an active role in this, this is where we’re going to end up.”

Her concerns are well founded. A recent survey sent by Dr. Monitto and her colleagues to members of the American Pediatric Surgical Association presented respondents with four scenarios wherein a child had undergone surgery and received pain medication in the hospital. “We asked them what they were going to send patients home with,” she explained. “And in three of the four scenarios, almost 50% of the respondents said they would send the patient home with no opioid.

“So they’re hearing the right thing, but are they deciding that ‘just say no’ is what they’re going to do moving forward?”

Nevertheless, the risk for opioid misuse is real. “There’s a 6% chance that adults who get a prescription opioid after surgery go on to chronic opioid use,” Dr. Monitto explained. “But patients 15 years old and younger—who are a large portion of our population—are actually at a much lower risk.”

There is another aspect of opioid diversion that many physicians often overlook, noted Dr. Davis, who is a member of the Anesthesiology News editorial advisory board. “What do you do when you have a child who requires opioids but you’re worried that the parents might be opioid abusers?” he asked. “That’s an equally serious problem.”

In the end, Dr. Monitto said prescribing opioids to both children and adults is a balancing act that requires insight and vigilance on the part of prescribers. “None of us can deny the extent and tragic consequences of the opioid epidemic,” she said. “But as we wait for better and safer drugs, we all have a responsibility to embrace safe prescribing and dispensing. At the same time, we can’t allow the pendulum to swing back so that our patients are denied legitim ate relief of very real pain.”

Dr. Davis agreed that providing sufficient pain relief is the anesthesiologist’s primary mandate, but looked to future research to help address the crisis. “We need to be developing research endeavors that look into developing opioid-free anesthesia,” he said. “And that’s not just by saying ‘multimodal analgesia,’ but actually coming up with regimens that work.”