M.N. Perez1,2, L. Huang1, W.L. Schäfer1, A.J. Lehane1, A. Moturu3, S. Kennedy4, C.J. Aprahamian5, S.B. Pillai6, B.J. Slater7, J.L. Holl8, M.V. Raval1,4 1Northwestern University Feinberg School of Medicine, Center For Health Services And Outcomes Research, Institute Of Public Health And Medicine, Chicago, IL, USA 2University Of Alabama at Birmingham, Department Of Surgery, Birmingham, Alabama, USA 3American College Of Surgeons, Division Of Research And Optimal Surgical Care, Chicago, IL, USA 4Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Division Of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA 5Children Hospital Of Illinois / OSF Saint Francis Medical Center, Division Of Pediatric Surgery, Department Of Surgery, Peoria, IL, USA 6Rush University Medical Center, Division Of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA 7University of Chicago, Comer Children’s Hospital, Division Of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA 8University Of Chicago, Department Of Neurology, Biological Sciences Division And Center For Healthcare Delivery Science And Innovation, Chicago, IL, USA
Introduction:
The Food & Drug Administration (FDA) and the Centers for Disease Control & Prevention (CDC) both caution against co-prescribing of opioids and benzodiazepines given the increased risk of central nervous system depression and risk of benzodiazepine physical dependency. This concern is particularly relevant in pediatric populations, where the developing brain may be more vulnerable to the adverse effects of these medications. This study sought to evaluate opioid and benzodiazepine co-prescribing for pediatric patients undergoing surgery and to investigate factors associated with this prescribing practice.
Methods:
This cross-sectional, retrospective study used data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) registry and patients’ electronic health records from 4 hospitals in Illinois, over two years (2021-2023). The cohort consisted of children, 5-18 years old, who underwent any operation included in the NSQIP-P sampling frame. The primary outcome was “co-prescribing,” defined as concurrent prescriptions for both an opioid and a benzodiazepine at discharge. Kruskal-Wallis and Wilcoxon rank-sum tests were performed for bivariate analyses. Using a multivariable logistic regression, patient- and procedure-specific factors associated with co-prescribing were identified (p<0.05).
Results:
Of the included 1,670 pediatric surgical patients, 217 had new or active prescriptions for both an opioid and a benzodiazepine at discharge (34% opioid, 17% benzodiazepine, 13% both). Co-prescribing varied significantly by hospital (1.7-19.5%, p=0.001) and surgical subspecialty (0-48.1%, p=0.001) (Table). Among discharge opioid prescriptions, total morphine milligram equivalents (MME) was significantly higher when the patient was also co-prescribed a benzodiazepine (p<0.001). Co-prescribing was associated with hospital site, age (OR=1.2, 1.1-1.3), male sex (1.8, 1.2-2.8), Orthopedic Surgery (33.3, 20.1-55.2), Urology (0.2, 0.0-0.8), and prescription of an additional non-opioid analgesic (e.g., acetaminophen/Tylenol) at discharge (7.4, 3.7-15.0).
Conclusion:
Wide variation exists in co-prescribing of opioids and benzodiazepines by hospital and surgical subspecialty. While benzodiazepines may be prescribed as part of a multimodal analgesia regimen, this study found benzodiazepines did not limit opioid prescribing, but rather were associated with a higher opioid dose intensity. Future work should focus on optimizing when co-prescribing is necessary.