Wednesday, April 3, 2019

Opioid prescribing practices for pediatric headache

Meckler GD, Sheridan DC, Charlesworth CJ, Lupulescu-Mann N, Kim H, Sun BC. Opioid Prescribing Practices for Pediatric Headache. J Pediatr. 2019 Jan;204:240-244.


To characterize the frequency of opioid prescribing for pediatric headache in both ambulatory and emergency department (ED) settings, including prescribing rates by provider type.

A retrospective cohort study of Washington State Medicaid beneficiaries, aged 7-17 years, with an ambulatory care or ED visit for headache between January 1, 2012, and September 30, 2015. The primary outcome was any opioid prescribed within 1 day of the visit.

A total of 51 720 visits were included, 83% outpatient and 17% ED. There was a predominance of female (63.2%) and adolescent (59.4%) patients, and 30.5% of encounters involved a pediatrician. An opioid was prescribed in 3.9% of ED and 1.0% of ambulatory care visits (P < .001). Pediatricians were less likely to prescribe opioids in both ED (-2.70 percentage point; 95% CI, -3.53 to -1.88) and ambulatory settings (-0.31 percentage point; 95% CI, -0.54 to -0.08; P < .001).

Opioid prescribing rates for pediatric headache were low, but significant variation was observed by setting and provider specialty. We identified opioid prescribing by nonpediatricians as a potential target for quality improvement efforts.

Overall, 1.5% of headache visits resulted in a prescription for opioids. However, the rate of opioid prescribing in the ED (3.9%) was higher than the 1% rate of prescribing for all ambulatory settings combined. The mean dose of opioid dispensed in the ambulatory setting was 103.5 morphine mg equivalents (MMEs) per day compared with 73 MMEs per day for opioids dispensed after an ED visit.

Hydrocodone was the most common opioid prescribed (54%), followed by codeine (38%) and oxycodone (8%). Regardless of setting, opioids were less often prescribed by pediatric providers. No differences were found in opioid prescribing rates by patient sex, and older teens (13-17 years) with headache were slightly more likely to receive an opioid prescription than were preteens (7-12 years).

A hint of a silver lining was seen in an overall decline in opioid prescribing for pediatric headache from 2012 to 2015. Although rates of opioid prescribing for pediatric headache are generally low, the higher rates seen in the ED and in conjunction with visits to nonpediatric providers suggest opportunities for intervention.

The finding of a low rate of opioid prescribing for kids with headache is good news, but even at a low rate, opioids are prescribed to thousands of children annually. The study authors point out several issues with evaluating opioid prescribing. First, many other studies have shown a general decline in opioid prescribing for children in the past decade.

That's good news, but the frequency of prescription is only part of the issue. Focusing on whether the prescriptions are appropriate in the first place is important.

This study also shows another aspect of the opioid epidemic that is not revealed in looking at overall prescribing rates: the daily dose delivered. Current recommendations for patients of all ages suggest cautious prescribing (≥ 50 MMEs/day) and reserving doses ≥ 90 MMEs per day for opioid-dependent patients. So it stands to reason that we should be even more judicious for kids.

The fact that the daily dose delivered in the ambulatory setting averaged more than 100 MMEs/day and more than 70 MMEs/day in the ED setting is concerning. Opioid-naive patients, particularly children, should not need such high doses. Paying attention to the daily dose delivered is another opportunity for opioid stewardship.

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