Opioid prescribing rates on 14-year decline in pediatric orthopaedic injuries, decreased by more than 50%

ROSEMONT, Ill. (May 19, 2020)—Prevention efforts to combat the opioid crisis by limiting early exposure are working in the pediatric population, according to a study released as part of the American Academy of Orthopaedic Surgeons’ (AAOS) Virtual Education Experience. The study found that between 2004 and 2017 opioid prescription rates decreased from 60% to 27.8%, a 52% drop, in pediatric patients between 10-18 years old who sought care for a minor fracture or dislocation in an acute care setting. However, patients in the South and Midwest were more frequently prescribed opioids, pointing to a need for further preventative measures.

In 2016, 769,000 children 12-17 years old misused opioids, according to the 2017 National Survey on Drug Use and Health.[i] Between 1999 and 2016, 8,986 children and adolescents died from prescription and illicit opioid poisonings.[ii] The use of prescribed opioids in high school led to a 33% increase in the risk of abusing opioids in the future, according to a 2015 study.[iii] Abusing opioids at an early age can serve as a gateway drug to more dangerous opiates, such as heroin.[iv]

“The statistics on opioid-related misuse are alarming and reducing the use of opioids in pediatric orthopaedic patients is essential,” said John M. Flynn, MD, FAAOS, chief of the Division of Orthopaedic Surgery at Children’s Hospital of Philadelphia. “As orthopaedic surgeons, we have a responsibility to realize that our surgical patients are more likely to die from their pain medicine than from the injury or operation.”

The researchers conducted a retrospective review utilizing 14 years (2004-2017) of data from the Pediatric Health Information System (PHIS) to identify emergency department (ED) and clinic visits for the 10 most frequently encountered pediatric fractures and dislocations. Patients included in the study, “Getting the Message: The Declining Trend in Opioid Prescribing for Minor Orthopaedic Injuries in Children and Adolescents Over the Past 14 Years,” had minor injuries that were managed without an operation and were sent home the same day. It included a total of 120,002 patients from 42 pediatric hospitals with an age range of 10-18 years old. Patients were categorized into four regions – Northeast, Midwest, South and West – based on the hospital location. A mixed effects logistic regression model was used to account for hospital variation.

The study found:

• Over 65,000 patients (54.3%) received at least one dose of opioid during their visit.
• Of those, 73.2% male and 52% were insured through a non-government plan.
• Patients 13-17 years old were 11% more likely to receive an opioid prescription than younger patients (p<0.001).
• African American patients were 39% less likely to receive an opioid prescription than Caucasian patients, which has also been observed in adult populations (p<0.001).

“We were happy to see the overall decline in prescription rates for opioids, especially with such a large data set,” said Divya Talwar, PhD, MPH, BDS, clinical outcomes research manager for the Division of Orthopaedics at Children's Hospital of Philadelphia. “The results indicate that the efforts to combat earlier exposure to opioids are having success in changing the prescribing habits of physicians in an acute care setting. However, we were definitely surprised that 54% of patients were still getting an opioid for an injury when they shouldn’t, demonstrating we still have work to do to reduce rates further.”

Regional differences were seen in the analysis. As noted, patients in the South and Midwest were more likely to be prescribed opioids compared to those in the Northeast (63% and 30% respectively); however, after adjusting for variation among different hospitals, these differences were found to be insignificant. The research team, which also included Jigar Gandhi, MD, PharmD, Cooper University Health Care and Arielle Krakow, BA, Children’s Hospital of Philadelphia, noted that the data did show that some regions weren’t limiting early exposure to opioids as much as other regions.

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Disclosure Statement

About the AAOS
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level to best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues and it leads the health care discussion on advancing quality.

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[i] Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf. Accessed Feb. 6, 2020.

[ii] Gaither, JR, Shabanova V, Leventhal JM. US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558.

[iii] Miech R, Johnston L, O'Malley PM et al. Prescription opioids in adolescence and future opioid misuse. Pediatrics. 2015;136(5):e1169–e1177.

[iv]  Carlson RG, Nahhas RW, Martin SS et al. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: a natural history study. Drug Alcohol Depend. 2016;160:127–134.