Pediatric Opioids And Pain Control In Fractures
Overview
It has been observed over time that pediatric patients who go through a closed reduction of fractures to the forearm with standard sedation in the emergency room are given opioids around 14 times the normal amount used at discharge. It has also been observed that non-opioid analgesics given to these patients are better tolerated, less prone to abuse or addiction, have fewer side effects, and are equally effective as opioids.
This two-part study was carried out to determine the patterns of opioid prescription and its use in pediatrics for pain relief following previous closed reduction procedure for pediatric fractures to the bones of the forearm.
Two types of studies were carried out to assess the use of opioids among the pediatric population following a closed reduction of forearm fractures for pain relief.
The first part of the study was a retrospective study which was carried out between 2016 December to 2018 January. The retrospective study was conducted at a level one trauma center to assess the habits or patterns of opioids prescription for patients aged 1 year to 17 years following closed reduction of forearm fractures.
The second part of the study was a prospective study carried out between 2019 August and 2020 October. It was done to assess pain management and use of opioids following discharge. Information was obtained through telephone surveys on days 1, 3 and 5 after discharge and chart reviews to assess pain scores and the use of opioids.
Participants including 50 patients with a median range of 8, and 51 patients with a median age of 9 were included into the prospective and retrospective studies.
It was noted that 21 patients (42%) from the retrospective study were prescribed 8-12 (median value of 10) opioid doses at discharge.
12 patients (24%) from the prospective study were given 5.5-10 (median value of 8) doses at discharge.
It was noted that initial pain scores and higher weight were related to an increase in the rate of prescription of opioids.
In this study, it was hypothesized that adequate pain management could occur with little or no need for opioids following discharge, leading to a sizeable amount of unused prescribed opioid doses.
Introduction
The United States is well-known to face an epidemic of opioid abuse. One of the major culprits responsible for opioid abuse is over prescription of opioids by medical practitioners or doctors. Data obtained from the Centers for Disease Control and Prevention (CDC) stated that around 247,000 people died from opioid overdoses related to prescriptions in the United States. Opioid prescriptions continue to rise among children ages 0-17 years, with up to 2.5 million prescriptions given to pediatric patients in 2012.
Also, opioid misuse in the pediatric population is closely linked to an increased risk of long-term effects and adverse behaviors, such as continuous use of opioids and heroin in adolescence.
Opioids are commonly given to children after surgeries and non-invasive procedures in managing orthopedic injuries. However, rules and protocols regarding prescription of opioids, duration of use and amount prescribed vary to a great extent among hospitals and medical professionals.
Practice specific and provider specific guidelines have been laid down by the American Academy of Orthopedic Surgeons to lower opioid use. It is necessary for opioid administration in children to be standardized with guidelines and protocols.
Although some previous studies have recorded opioid over prescription in children after surgery, only 3 of these studies have highlighted the usage of the opioids at home.
A study conducted by Nelson et al in 2019 demonstrated that patients used more than 25% of opioids doses prescribed after percutaneous pinning and closed reduction of supracondylar fracture to the humerus.
Another study conducted by Stillwagon et al in 2020 found that only an average of 4 opioid doses out of a mean of 47 doses were used for pain management after surgery.
A third study conducted by Keil et al in 2021 evaluated the use of opioid after all operative fractures in pediatrics with exception of supracondylar fracture to the humerus. It was determined that opioid prescriptions were still 4 – 5 times more than the amount required for pain management.
The 3 studies were published in the midst of a rise in opioid abuse nationwide, which led to the development of an initiative in August 2019, targeted at standardizing the prescription of opioids in pediatrics for patients who present with orthopedic-related conditions. This initiative caused a change in the prescription habits of physicians in the emergency department and orthopedic surgeons in the prospective and retrospective portions of this study.
Opioids have been seen to be over prescribed, with prescription doses being significantly higher than what the pediatric patient who went through a closed reduction of fractures to the forearm really takes. Considering the opioids abuse crisis, the area of opioid over prescription is a vital area which should be addressed.
Method
This study was a combination of prospective observational and retrospective cohort studies at a level one trauma center pediatric emergency room in the Southeastern United States.
The study was carried out in accordance to the STROBE protocol for observational studies, and given approval by the local institutional review board (IRB).
Retrospective Study
In the retrospective study, information was obtained from the electronic medical records (EMR) chart review and documented on the REDCap database. Information gotten includes: the patient’s demographic information, type of fracture sustained, pain score in the emergency room and follow-up visit, type of analgesic given in the emergency room and its dose, type of analgesic prescribed following discharge and its dose.
The number of opioid doses prescribed following discharge from the emergency room was used to assess the primary outcome of the study.
The total dose of analgesics given in the emergency room and after discharge were obtained to determine the possible relationship between pain score at presentation and the analgesic given.
Extra details like patient’s age, weight, sex, pain score on presentation and pattern of the fracture were obtained to ascertain other factors related to prescription of opioids at discharge.
Inclusion Criteria
Selected participants included patients between the ages of 1 and 17, who had undergone a closed reduction of fractures to the forearm under sedation in the emergency room between 2016 December and 2018 January.
Current Procedural Terminal codes were used to identify participants for sedation and further selected with a manual chart review. Displaced fractures, sufficiently angulated fractures or fractures that have been deemed eligible for sedation and close reduction were included in the study.
Exclusion Criteria
Fractures that were minimally displaced or non-displaced were excluded from the review.
Additionally, patients who were lost to follow-up, who had missing pain scores or analgesic prescribing data, had an operative procedure to manage the forearm fracture, or who were admitted into the hospital instead of being discharged were excluded from the study.
Statistical Analysis
Statistical analysis was carried out via t tests, Kruskal-Wallis year and x² tests with several variables being analyzed to reach significant levels.
P < 0.05 was the set significance level.
Prospective Study
At least 50 patients were identified, and their data collated between 2019 August and 2020 October.
Patient’s demographic data, type of fracture, pain score and analgesic given in the emergency room and after discharge were gotten through a chart review. Also, specific data was collected on the kind of analgesic medication given, it’s route of administration, frequency of intake and total amount of doses given.
All participants were then reached out to on post injury days (PID) one, three and five. Surveys were also carried out via a phone call with the caregivers of the patient. In any case that the caregiver is not available, a brief voicemail is left, describing the study and when they would call next.
Three calls in total were made in the course of one day. If the caregiver is still not available for all 3 calls, the patient was then excluded from the study.
Following an informed consent given by the caregivers, the patient’s opioid and analgesic use and pain scores are gotten over the phone and recorded.
Caregivers were asked to use the FLACC scale to rate the pain the child felt for younger patients who can’t express their pain score. The FLACC scale assesses the child’s face, legs, activities, cry and consolability in response to the pain felt.
Older patients who were able to express their pain score were asked to rate their pain on a scale of 0 to 10.
Patient pain scores from previous follow up visits were then gotten by EPIC chart review. Results collected were documented and managed via REDCap.
The pain severity scores on post injury days one, three and five and at first follow up after discharge were used to assess the primary outcome.
Total analgesic doses given in the emergency room and after discharge were gotten to determine any correlations.
Additionally information on variables like patient sex, weight, age, pattern of fracture and pain scores on presentation were taken to ascertain any extra correlations.
Inclusion Criteria
Patients aged 1 to 17 years who had gone through a closed reduction for fractures to the forearm in the emergency room, were selected by the daily screening of an electronic medical record (EMR) list kept by the department of orthopedic surgery.
Fractures that were displaced, well angulated or deemed eligible for sedation and closed reduction were also included in the study.
Exclusion Criteria
Fractures that were minimally displaced or non-displaced were excluded from the study. Additionally, patients who were not English speaking were excluded.
Statistical Analysis
Statistical analysis was carried out via t tests, Kruskal-Wallis test and x² tests to analyze several variables and reach significance levels. P < 0.05 was the set significance level.
Results
Retrospective Study
A total of 62 charts were reviewed to be included in the study. 12 of the 62 charts were excluded due to lack of follow up, admission into the hospital, operative management of fractute and missing data.
The study consisted of children with a median age of 8, including 17 (34%) females and 33 (66%) males.
Patterns of fractures seen among participants include 31 (62%) fractures to both the radius and ulna, 15 (30%) fractures to the radius alone, 4 (8%) fractures to the ulna alone.
34 out of 50 (68%) patients were given opioid in the emergency room. The opioid most commonly given in the emergency room was morphine (71%), then oxycodone (32%) and fentanyl (29%).
Following discharge, opioids were prescribed for 21 (42%) patients with a median opioid dose of 10 doses.
Of all opioids, oxycodone was the only one that was prescribed to patients after discharge.
Median pain score at presentation was 6 out of 10, with an average time of the next follow-up visit being 8 days.
Median pain score on follow up was zero out of 10.
The highest amount of opioid doses given to a patient was 16, while the lowest amount of opioid dose given to a patient was 5.
There was no correlation between opioid prescription after discharge and the patient’s age, sex and type of fracture.
There was also no correlation between prescription of opioids and the patient’s pain score at presentation or follow-up.
Prospective Study
111 pediatric patients who had undergone closed reduction for forearm fractures were identified.
5 out of 111 were not English speaking, and as such, were excluded from the study.
Also, 51 patients out of the remaining 106 patients had completed the surveys and we’re included in the study. 30 patients did not take the post injury day (PID) 1 phone call, 6 patients did not take the post injury day (PID) 3 phone call, 5 patients did not take the post injury day (PID) 5 phone call and 5 did not show up for follow up in the hospital.
Patients in this study had a median age of 9, including 22 (43%) females and 29 (57%) males, with a median weight of participant being 30.8kg.
The patterns of fracture included in this study were 34 (67%) fractures of both radius and ulna, 13 (25%) fractures of radius alone and 4 (8%) fractures of the ulna alone.
There was a significant correlation between the opioid prescription given and the patient’s age and weight. There was however, no significant correlation between opioid prescription given and the patient’s sex.
There was no significant variance between the type of fracture involved and pain scores at presentation and the amount of opioid doses given after discharge.
Median pain score at presentation was 7 out of 10.
There was a correlation between higher pain scores at presentation and opioid prescription after discharge. Patients with a median pain score at presentation of 8 out of 10 were prescribed opioids after discharge, while patients with median pain score of 6 out of 10 were not given opioids after discharge.
The highest amount of prescribed opioid doses was 18, while the smallest amount of prescribed opioid was 3.
Of the opioids involved, oxycodone was most commonly given, then hydrocodone-acetaminophen.
Of 12 patients who were given opioid prescriptions after discharge, only 3 took some of the drugs, with only one patient taking them after the post injury day (PID) 1.
7 out of the 98 total opioid doses given to all patients were used.
75% of patients did not take any opioid doses after they were prescribed.
Conclusion
Opioids remain a center of research owing to the over prescription of opioids and the resultant opioid abuse crisis.
There is a lingering need for improvement in the patterns of opioid prescription, especially among the pediatric population. There is increasing evidence that many pediatric fractures treated operatively may not need opioid analgesia outpatient or after discharge. Also, little to no opiates may be necessary for pain relief following closed reduction of fractures.
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