Opioid Analgesic Utilization in Pediatric Population with Acute Pain

Background: Opioid epidemic is a long-standing challenge faced by the United States with millions of children and adolescents being exposed to opioids and its harmful effects. Statewide opioid prescribing policies, pediatric opioid analgesic guidelines and FDA warnings have been implemented in an effort to minimize opioid utilization in the pediatric population as well as recommending other analgesic alternatives to manage pain. However, guidelines and policies have an intended and an unintended effect. Objective: The overarching goal of the dissertation project was to examine the intended and unintended consequences of guidelines and policies that were instituted to reduce opioid use in children in the light of the opioid epidemic To achieve the goal, the following three aims were investigated: Aim 1: To evaluate the association between initial opioid analgesic prescription duration and receipt of repeat opioid prescription in children and adolescents; Aim 2: To examine the association between outpatient post-surgical analgesic prescription and risk of insufficiently managed pain such as additional analgesic dispensing and pain-associated hospital admission and ER visit; and Aim 3: To determine the change in repeat opioid analgesic prescription trend in children and adolescents experiencing acute pain. Methods: The study included children and adolescents 1–17 years of age who were enrolled in a large Medicaid Managed Care plan and filled an incident opioid analgesic prescription (Aims 1, 2 and 3) or an incident non-opioid analgesic prescription (Aim 2) during 2013–2018. A hierarchical multivariable logistic regression model with patients nested under prescribers was fitted to test that (i) the association of initial opioid analgesic prescription duration and the likelihood of receiving a repeat prescription (Aim 1) and (ii) the risk of having additional pain-related service utilization associated with analgesic modality (Aim 2). A generalized linear regression analysis was conducted to examine changes in repeat opioid analgesic dispensing over time at quarterly intervals (Aim 3). Results: Of 17,086 incident opioid recipients 10.4% received a repeat opioid analgesic. The multilevel model indicated that after controlling for patient characteristics, diagnoses and procedures associated with initial opioid prescription, children receiving 4–7 days’ supply [aOR: 0.98(0.9–1.1)], 8–10 days’ supply [aOR: 1.03(0.8–1.3)], and >10 days’ supply [aOR: 0.85(0.7–1.1)] had comparable likelihoods of receiving a repeat opioid analgesic prescription as those receiving 1–3 days’ supply (Aim 1). Of the children undergoing outpatient procedures, 42.3% received incident opioid and 57.7% received incident non-opioid. Around 15% patients in opioid and non-opioid groups had pain-related service utilization. The multilevel model indicated that initial opioid analgesic recipients were two times more likely than non-opioid analgesic recipients to receive an additional analgesic dispensing [aOR: 2.33(95%CI: 2.0–2.8)] and 60% less likely of having a pain-associated hospital admission or ER visit [aOR: 0.41(95%CI: 0.3–0.5)] (Aim 2). There was a significant decline in repeat opioid trend from 11.5% in Q1, 2013 to 9.6% in Q4, 2018 with a quarterly percentage change (QPC) of 6.8% decline (95%CI: 0.6%–12.6%). Conclusion: Initial opioid analgesic duration was not associated with the risk of receiving a repeat opioid analgesic prescription (Aim 1). In 15% of patients who required additional pain management beyond the initial analgesic prescription following an outpatient procedure, those initiated on opioid analgesics are more likely to receive additional analgesics, while those initiated on non-opioid analgesics are more likely to have pain-associated ER visits and hospital admissions (Aim 2). There has been a steady decline (~7% per quarter) in repeat opioid analgesic dispensing between 2013 to 2018 (Aim 3).