Pediatric Postoperative Pain Management at Home Barriers in Assessment and Treatment

Marcia L. Buck, PharmD, FCCP, FPPAG, BCPPS

Disclosures

Pediatr Pharm. 2016;22(8) 

In This Article

Appropriate Prescribing of Opioids

In 2015, Abou-Karam and colleagues at Sainte-Justine University Health Center evaluated prescriptions for analgesia given to the families of 243 children (median age 4 years) following outpatient surgery at their institution.[9] The surgeries were most often otolaryngology procedures (55%), urologic or gynecologic procedures (14%), or orthopedic procedures (12%). All patients were given a prescription for morphine (median dose 0.19 mg/kg, range 0.03–0.41 mg/kg). The primary outcome of the study was administration of morphine as directed. Prescriptions were divided into those with instructions for regularly scheduled doses (47%) and those for a dose to be given as needed (53%). A total of 186 families (85%) had the prescriptions filled at a pharmacy. Of those families who chose not to fill the prescription, 70% gave as their reason that the child had no pain or mild pain that was relieved with acetaminophen. Only six families stated that they were unwilling to give their child morphine.

Of the 104 families given the prescription for regularly scheduled morphine, only 56% gave it as prescribed. The most frequent reason for variance was that their child had no pain or responded adequately with doses given on an as needed basis. Five families related negative perceptions about morphine and another six were concerned for adverse effects. These parents and guardians were able to correctly describe opioid adverse effects. Other common reasons for variance were the child's refusal to take the medicine in seven cases and not wanting to wake the child at night in four cases. In the families given the as needed prescriptions, 85% adhered to the regimen. In the families who had the prescription filled, the majority of the children (63%) received two or fewer doses of morphine. For the patients in both groups who received morphine, the most common adverse effects were drowsiness (18%), vomiting (17%), constipation (15%), and nausea (9%).

In a subset of 77 patients for whom complete prescription information was available, the median number of prescribed doses was 18 (IQR 10–20) while the median number actually given was one (IQR 0–3). Fifty-five percent of families returned the remaining morphine to the pharmacy, while 27% disposed of it at home. Only 9% of parents stated that they kept the remaining morphine at home for later use, a much lower percentage than reported in previous studies.

While this study confirms that children undergoing outpatient surgery typically have pain for several days, many required only OTC analgesics after the first couple of days following surgery. In light of the results of the study, and the knowledge that many families keep the remaining medicine in the home, the authors suggest the need for thoughtful consideration of the total number of opioid doses prescribed for pediatric outpatient surgeries. Reducing the available number of opioid doses to that expected to be needed, with additional instructions for the use of OTC analgesics and the availability to contact a healthcare provider if pain continues, may lessen opioid exposure in children and reduce the risks for adverse effects, accidental ingestion, or abuse by others.

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