A summary of a rebuttal from pediatric pain experts
(Agarwal, Hays, Chidambaran) regarding opioid use
A November 2020 article in JAMA Surgery reported the findings of a multidisciplinary team of health care experts and leaders in opioid stewardship to review current literature and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.
This original JAMA article underscored 3 primary themes:
1 health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids
2 non0pioid analgesic use should be optimized in the perioperative period
3 patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery
I would encourage the interested reader to review the original paper themselves with particular attention to Table 1 Guidelines for Opioid Prescribing in Children and Adolescents After Surgery.
I will post the summary of this article at a later date.
Today I will summarize my understanding of the recent article dated March 8, 2021 from Drs Agarwal, Hays, and Chidambaran, three pediatric anesthesiologists with interest in acute post-surgical pain management. A link to the article can be found at the bottom of this post.
The authors agree that, while they too are concerned with the inappropriate use of opioids in the surgical population, they caution that the guidelines published in the JAMA article have not adequately addressed the intricacies of pediatric pain management. The journal publication, JAMA Surgery, stands as a respected resource in the medical world and these guidelines may unnecessarily scare families and mislead the physicians looking for guidance in opioid management.
The authors go on to identify that although opioid-free recovery is ideal, it is frequently not feasible given that some procedures are associated with intense pain and other modalities such as regional anesthesia techniques may not be completely effective or may not be feasible. And similarly, it may not be realistic--or wise-- for a patient to be expected to have an opioid-free recovery. Furthermore, opioid-free recovery is not supported by clinical evidence and may set unrealistic surgical and recovery expectations for the patient and their family.
The authors also acknowledge that inadequate pain management impacts healing and recovery. Poorly controlled acute postoperative pain is a predisposing factor for chronic postsurgical pain (CPSP) in adults and children.
(My thoughts --> And prevention of CPSP warrants appropriate medications, local anesthetic techniques, validation of pain, attention to anxiety and psychological frame of mind of patient and family, sleep hygiene, nutrition, guidance regarding activities of daily living, thoughts about pain, etc. It is COMPLEX.)
Lastly, opioid addiction and diversion among adults is well documented; however, research shows that only a small minority of adolescents misuse opioids and other controlled substances. The authors are acknowledging that, as prescribing providers, we need to be concerned about opioid misuse, but most children are not the major contributors to the opioid crisis.
We need to take accountability for our contribution while we continue to treat those individuals undergoing procedures associated with intense pain in a compassionate and responsible manner, even using opioids when warranted along with other multimodal agents.
The authors agree that opioids should be used sparingly post-operatively, but fear of misuse and addiction should not prevent appropriate pain management when opioid treatment is clinically indicated.
Ongoing parent and patient education about expectations for recovery post-surgery and proper pain management is needed. These are my suggestions below:
- multimodal strategies for pain management
- first-line agents such as acetaminophen / NSAIDs
- non-pharmacologic strategies initiated from the beginning
- consideration of regional anesthetic techniques
- standard operating procedure for pain management based on intensity of
expected pain with input from surgeons
- pro-active attention to pain management; the opportunity for service recovery
- initiating conversations with patients regarding pain
- focus on patient functioning in accordance with surgeon expectation
- appropriate treatment in the hospital (sometimes with opioids) does not necessarily
warrant at-home use of opioids
- recommendations to patients / parents to properly dispose of any medications to
prevent storing in home
- some pain IS normal and to be expected; this normalizes this concept
What are YOUR thoughts about this article?
Have you experienced a situation when a patient was told they could not have an opioid medication after a complicated surgery due to the risk of addiction or opioid misuse?
Have you seen colleagues properly address this topic with patients?
How can we break down the individual silos and come together to provide comprehensive care?
Share your thoughts and responses so we can all learn about the barriers and come up with solutions. Comment below or start a discussion in the forum.