Opioid Fills in Children Undergoing Surgery From 2011 to 2014

A Retrospective Analysis of Relationships Among Age, Initial Days Supplied, and Refills

Martha Wetzel, MSPH; Jason M. Hockenberry, PhD; Mehul V. Raval, MD, MS


Annals of Surgery. 2021;274(2):e174-e180. 

In This Article

Abstract and Introduction


Objective: The primary objective is to describe the relationship between the days supplied of postsurgical filled opioid prescriptions and refills.

Background: The American College of Surgeons (ACS) has called for surgeons to alter opioid prescribing to counteract the opioid epidemic while simultaneously providing pain relief. However, there is insufficient evidence to inform perioperative prescribing guidelines and quality metrics in children.

Methods: We performed a secondary data analysis of nationwide commercial claims from the Health Care Cost Institute (HCCI) data spanning 2010 and 2014. Based on initial opioid fill and refill rates for 11 common pediatric procedures, the refill analysis focused on anterior cruciate ligament repair, humerus fracture repair, cholecystectomy, posterior spinal fusion, and tonsillectomy.

Results: There were 178,990 cases with a median age of 6. Overall, 48.5% of patients filled an opioid prescription between 30 days before surgery through 7 days after surgery, and 14.2% filled a second opioid prescription within 30 days. There was a significant negative relationship between days supplied in the initial prescription and probability of a refill for humerus fracture, spinal fusion, and tonsillectomy. The largest effect was seen for tonsillectomy, with the odds of having a refill decreasing by approximately 12% for each day supplied in the initial prescription (odds ratio 0.88, 95% confidence interval 0.87–0.89, P < 0.001).

Conclusions: Pediatric postoperative opioid-prescribing guidelines need to be procedure-specific and based on patient age. We provide the days supplied associated with a 20% probability of a refill by age to further guideline development.


In 2016, there were 42,000 overdose deaths involving an opioid, with 19,000 of those deaths involving opioid pain relievers.[1] In addition to the risk of contributing to the epidemic of opioid abuse and overdose, opioid prescribing in the pediatric population poses a number of lower-profile risks. The adverse event rate for opioid prescriptions in the pediatric population has been estimated as 38.3 out of 100,000.[2] Due to routine side effects of opioids, emergency department visits are higher for patients receiving opioids than similar patients who did not receive an opioid.[3,4] Leftover opioids are of particular concern, given that the majority of patients have leftover medication,[5] and approximately 37% of adolescents who use opioids nonmedically report using their own leftover prescriptions as a source.[6] These statistics are even more concerning as we learn more about the long-term impact of drug exposure on adolescent brain development.[7] Legitimate opioid use before high school graduation is independently associated with a 33% increase in the risk of future opioid misuse after high school.[8]

Although the American College of Surgeons (ACS) has issued a call for surgeons to prescribe in a manner that addresses pain control and the opioid epidemic,[9] few evidence-based guidelines exist for postoperative prescribing.[10,11] Although there is general agreement that opioids are overprescribed, practices wishing to reduce prescribing face an immediate dilemma of determining their own guidelines. One approach to this problem has used pain diaries to gather data on actual opioid use for select procedures, such as laparoscopic cholecystectomy in the pediatric population[12] and inpatient surgeries in the adult population.[13,14] These studies provide valuable information, but are limited to a few procedures and single-institution research. Consequently, prescribing practices are currently highly variable,[3,15,16] and quality improvement initiatives are not consistently research-based.[17]

Refill requests are routinely used as a metric to indicate whether reductions in quantity prescribed have negatively affected patients' pain control.[17] Refill requests create burden for both the provider and patient. As a result, physicians may write large prescriptions in an attempt to avoid all refill requests,[11] a practice that, in turn, results in high numbers of unused pills. One approach to determining the optimal amount of postsurgical opioids used patient surveys to measure the amount of opioids required to meet the needs of 80% of patients.[18] In this study, we used refills as an indication of initial prescription sizes that fail to meet patient needs. As a first step toward filling the knowledge gap related to minimum sufficient prescription sizes, we examined the relationship between initial quantities supplied and refill requests in a population of privately insured pediatric patients undergoing common inpatient and outpatient surgical procedures.