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Opioid Prescribing Practices after Pediatric Urologic Surgery
Lauren E. Corona, MD1, Elizabeth B. Roth, MD2, Angela Thao, BS2, Muzi Lin, BA1, Ted Lee, MD1, Calista M. Harbaugh, MD1, Samir K. Gadepalli, MSc, MD, MBA1, Jennifer F. Waljee, MD, MPH1, Courtney S. Streur, MD, MS1.
1University of Michigan, Ann Arbor, MI, USA, 2Medical College of Wisconsin, Milwaukee, WI, USA.

Background: Surgery is a leading cause of the prescription of excess opioids, which are most commonly not stored safely or disposed of after their use. This places children and others in the home at risk for accidental ingestion or intentional misuse, which may explain the increasing incidence of opioid overdose among children. Without procedure-specific post-operative prescribing guidelines, surgeons currently prescribe based on their own assumptions of perceived post-operative pain. As part of an effort to standardize opioid prescribing guidelines across two large academic centers without a current policy, the purpose of this study is to evaluate the current prescribing practices after the most common ambulatory pediatric urology procedures to identify areas in need of improvement.
Methods: We retrospectively collected data on post-operative opioid prescriptions after the most common pediatric urology ambulatory procedures, circumcision and inguinal surgeries (orchiopexy and hernia/hydrocele). Children ages 0-18 years who underwent surgery between 2016-2017 at two large academic centers were included. Bivariate analysis was performed using non-parametric tests. Multivariable logistic regression was performed to determine factors associated with prescription of greater than the study population's mean number of opioid doses for each procedure.
Results: Over the two-year period, 811 circumcisions and 883 inguinal surgeries were performed. 94% of patients undergoing a circumcision and 97% of those undergoing an inguinal surgery received an opioid prescription. The mean number of doses prescribed for circumcision was 21.54; for inguinal surgeries, 23.54 (Table 1). 75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p<0.01). There was significant variation in opioid prescribing patterns by provider (p<0.01) (Figure 1). On multivariable logistic regression, younger age, surgeon, and earlier year were all associated with a greater number of opioid doses prescribed.
Conclusions: This multi-institutional study, the largest study to date for pediatric urologic surgeries, statistically suggests that without a formal opioid prescribing policy, there is significant variability in opioid prescribing patterns. It further demonstrates that opioid prescribing after pediatric urologic surgery is exceedingly common, being done in nearly every case. Alarmingly, younger patients were the most likely to be prescribed the highest number of doses. Considering that recent studies have shown successful opioid free pain management after urologic surgery in adult patients, opioids were likely prescribed in great excess in our pediatric population. These results highlight the urgent need for clear, procedure-specific prescribing guidelines in order to prevent leftover opioids in the home, which could lead to overdoses, persistent use, and intentional misuse.
Table 1. Mean number of opioid doses prescribed based on patient and surgery characteristics.

CircumcisionInguinal Surgery
Mean number of opioid dosesp-valueMean number of opioid dosesp-value
AGE
0-223.05 (SD 12.70, range 0-87)<0.0125.92 (SD 13.35, range 0-100)<0.01
2-519.34 (SD 12.74, range 0-71)21.39 (SD 11.21, range 0-72)
5-1016.78 (SD 6.55, range 4-40)20.60 (SD 11.73. range 0-100)
>1021.69 (SD 21.69, range 5-40)24.91 (SD 12.80, range 0-80)
SEASON
Spring24.26 (SD 11.89, range 0-72)<0.0125.95 (SD 12.81, range 0-74)<0.01
Summer19.07 (SD 9.35, range 0-65)22.70 (SD 12.94, range 0-100)
Fall19.95 (SD 11.89, range 0-72)22.18 (SD 13.57, range 0-100)
Winter21.28 (SD 9.69, range 0-62)21.14 (SD 9.79, range 0-84)
PRESCRIBER*
Resident24.62 (SD 13.18, range 4-87)0.0925.11 (SD 10.72, range 5-60)0.27
Attending21.76 (SD 10.42, range 4-87)26.68 (SD 14.53, range 6-100)
INSTITUTION
117.59 (SD 7.06, Range 5-62)<0.0119.00 (SD 7.85, range 0-80)<0.01
223.24 (SD 13.05, Range 0-87)25.78 (SD 14.12, range 0-100)
YEAR
201622.70 (SD 12.71, Range 0-87)<0.0125.23 (SD 13.83, range 0-100)<0.01
201719.68 (SD 10.09, 0-77)21.32 (SD 10.92, range 0-84)

*Known for only 1 institution

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