Reducing Post-Tonsillectomy Opioids May Be Feasible in Kids

Nicola M. Parry, DVM

August 09, 2019

Although 6 in 10 children receive opioids after tonsillectomy, these painkillers may not reduce the risk for complications they are prescribed to target, a recent study published online yesterday in JAMA Otolaryngology–Head & Neck Surgery has suggested.

"[H]aving 1 or more perioperative opioid prescription fills was not associated with fewer or more return visits for pain or dehydration or secondary hemorrhage than nonopioid use, but it was associated with increased risk of return visits for constipation," write Kao-Ping Chua, MD, PhD, from the University of Michigan, Ann Arbor, and colleagues.

Opioids have traditionally been used instead of nonsteroidal anti-inflammatory drugs (NSAIDs) after tonsillectomy in children to provide better pain relief and reduce bleeding risk.

However, some studies have begun to refute these assumptions. Opioid use may also be associated with serious adverse events, such as respiratory depression and even death.

Indeed, these side effects have led the US Food and Drug Administration to issue a black box warning against prescribing codeine and tramadol in children younger than 18 years.

As a result, clinical practice guidelines from the American Academy of Otolaryngology (AAO) recommend nonopioids as a first-line analgesic after tonsillectomy in children.

With this in mind, Chua and colleagues conducted a study of children who had undergone tonsillectomy. The study aimed to examine perioperative opioid prescribing patterns and investigate the link between analgesic prescribing and postoperative complications in children who receive opioids compared with those who do not.

The researchers analyzed a national sample of claims from a private insurance database between 2016 and 2017, including 15,793 children (aged 1 to 18 years) who had undergone a tonsillectomy.

The data showed that 9411 children (59.6%) had at least one filled opioid prescription from 7 days before to 1 day after tonsillectomy.

Prescription durations typically lasted for 6 to 10 days (median duration, 8 days). By contrast, most state and insurer limits tend to restrict opioid prescriptions to a 7-day supply for acute pain, the authors say.

Children who had one or more filled opioid prescriptions were not more likely than those who did not receive opioids to return to the medical facility, between days 2 to 14 post-surgery, with complications of pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% confidence interval [CI], 0.95 - 1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73 - 1.10).

However, children who received opioids were more likely to return because of constipation (AOR, 2.02; 95% CI, 1.24 - 3.28).

There was no association between prescription duration and return visits for pain or dehydration, secondary hemorrhage, or constipation.

Addressing the limitations of their study, the authors stress that these findings may not necessarily generalize to publicly insured children. In addition, having a filled opioid prescription does not mean that the children received the painkillers, and not returning for pain or dehydration does not rule out the possibility that a child experienced pain.

Similarly, because "the lack of perioperative fills does not imply NSAID use, the findings only suggest that opioids may not be superior to nonopioid regimens for preventing secondary hemorrhage," the researchers add.

Nevertheless, the results of this study potentially support the feasibility of reducing opioid prescribing in children after tonsillectomy, conclude Chua and colleagues.

This study was supported by the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, and the Centers for Medicare & Medicaid Services.

Study author Chad Brummett reports having a patent for peripheral perineural dexmedetomidine licensed to the University of Michigan; serving as a consultant for Recro Pharma and Heron Therapeutics Inc outside of the present work; receiving research funding from Neuros Medical Inc; and receiving grants from the National Institutes of Health-US Department of Health and Human Services, Michigan Department of Health and Human Services, National Institute on Drug Abuse, and University of Michigan Genomics Initiative, during the conduct of the study. Chua and the remaining authors have disclosed no relevant financial relationships.

JAMA Otolaryngol Head Neck Surg. Published online August 8, 2019. Full text

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