M. R. Freedman-Weiss1, A. S. Chiu1, S. L. Ahle1, R. A. Cowles1, D. E. Ozgediz1, E. R. Christison-Lagay1, D. G. Solomon1, M. G. Caty1, D. H. Stitelman1 1Yale University School Of Medicine,Department Of Surgery, Section Of Pediatric Surgery,New Haven, CT, USA
Introduction:
The complex issue of prescribing opioids balances recognizing opioids as a tool to reduce pain and as an addictive drug with a propensity to cause suffering. Adolescents who use prescription opioids have an increased risk for future drug abuse and overdose, making them a high-risk population. Appendectomy is one of the most common operations, often requires narcotic analgesia, and is performed by both pediatric and general surgeons. The opioid prescribing patterns of these two provider groups have not yet been compared; we hypothesize that pediatric surgery providers prescribe fewer opioids for adolescents than do general surgery providers.
Methods:
A retrospective chart review was conducted across a single health system consisting of four hospitals. All laparoscopic appendectomies performed between January 1, 2016 to August 14, 2017 on patients aged 7-20 were included for analysis. Any case coded for multiple procedures or identified as converted to open were excluded.
The primary outcome measure was amount of narcotic prescribed postoperatively. To standardize different formulations and types of analgesia prescribed, prescriptions were converted into Morphine Milligram Equivalents (MME). For reference, one 5 mg pill of oxycodone equals 7.5 MME. Patients were further grouped into quartiles based on amount of narcotic prescribed, with the top quartile classified as “high prescribing.” Logistic regression was performed evaluating odds of high prescribing, and incorporated patient weight, gender, race, insurance status, and service provider type (pediatric vs. general surgery).
Results:
A total of 336 pediatric laparoscopic appendectomies were analyzed, 148 by general surgeons and 188 by pediatric surgeons. Pediatric surgeons prescribed less narcotic than general surgeons overall (73.6 MME vs. 109.6 MME, p<0.001). For patients under the age of 13, there was no significant difference between pediatric (46.6 MME) and general surgeons (48.0 MME, p=0.8921). However, for the 13-20 age group, pediatric surgeons prescribed 28% less narcotic than general surgeons (93.2 MME vs. 130.1 MME, p<0.0001).
Regression analysis of patients 13-20 demonstrated that heavier weights (120-159lbs vs. <120lbs OR 4.6 95%CI[1.4-15.2]), ≥160lbs vs. <120lbs OR 5.5 95%CI[1.5-20.3]) and being cared for by a general surgery service (vs. pediatric surgery OR 5.2 95%CI[2.2-12.1]) were associated with high prescribing.
Conclusion:
After a laparoscopic appendectomy in a single hospital system, general surgeons prescribe significantly larger amounts of narcotic to adolescent patients than do pediatric surgeons. Although both provider types practice weight-based prescribing, even when controlling for weight, general surgeons are significantly more likely to be high prescribers. One substantial and modifiable contributor to the opioid epidemic is the amount of opioid prescribed, thus highlighting the need for education and guidelines on this topic.