DECREASE PRESCRIBING OF POSTOPERATIVE OPIOIDS IN PEDIATRIC ACL RECONSTRUCTION- TREATMENT TRENDS AT A SINGLE CENTER

Abstract

Background:

Pain control following ACL Reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Significant efforts have been made to reduce unnecessary opioid prescribing in this vulnerable population, but few have sought to define current practices.

Purpose:

The purpose of this study is to describe trends in postoperative pain management and assess factors that may mitigate overutilization of opioid medications.

Methods:

This is a retrospective review of a series of pediatric patients (<18yo) undergoing primary ACLR within an urban academic hospital system over a 5-year period (2014-2018). The period included the gradual introduction of preoperative consenting for opioid use in minors as mandated by state law in 2016. Patient demographics, surgical details, presence of opioid consent, prescribed postoperative medications, prescriber, and indicators of inadequate pain control were collected. Trends in medication prescribing were assessed. Univariate and multivariate analyses were performed to identify factors associated with reduced postoperative opioid prescribing.

Results:

This study included 687 patients with a mean age of 15.1±1.9 years. The majority underwent ACL reconstruction using hamstring autograft (92.0%) at our main hospital (54.9%). Postoperatively, discharge medication prescribing was performed most frequently (38.1%) by advanced practitioners (NP/PA). While there was no change in the proportion of patients prescribed opioids (>95% of patients) over the 5 year period, the mean number of doses dispensed decreased annually (Fig. 1). This was accompanied by an increase in the annual percentage of patients prescribed oral NSAIDs and acetaminophen during that period. Preoperative opioid consent was obtained in 31.9% of the cohort and these patients received significantly fewer doses of prescribed opioids (25.0 vs. 34.6 doses, p<0.001), while still having a lower rate of uncontrolled pain prompting early unplanned contact via telephone, ED or clinic. Preoperative consenting (IRR 0.764, CI 0.634-0.920, p=0.005) and satellite surgical location (IRR 0.712, CI 0.517-0.979, p=0.037) were identified as significant predictors of decreased number of postoperative opioid doses prescribed following multivariate regression analysis (Table 2).

Conclusion:

Total doses of postoperative opioids prescribed for pain management in pediatric ACLR have declined in recent years, which appears related to preoperative counseling through mandated opioid consenting and paralleled by greater utilization of non-opioid medications. Continued efforts should be made to identify measures to limit overreliance on these medications and to mitigate issues related to misuse, overdose and addiction.

Figure 1.

ACL Reconstruction Postoperative Pain Medication Prescribing Trends

Annual proportion of patients prescribed ibuprofen, acetaminophen and opioid medication postoperatively and the annual mean number of opioid doses prescribed.

Univariate and multivariate negative binomial regression analysis of factors associated with prescription of a greater number of postoperative doses of opioid medication. CI = Confidence Interval.