Providers caring for teens after surgery may misjudge how many opioid pills are needed, sometimes prescribing more or fewer than necessary. Prescribing too few opioid pills can offer too little pain relief. However, prescribing too many pills can raise concerns about addiction and safety of having unused opioids in the home.

“Most of our current efforts to curb opioid overprescribing have focused on provider-to-provider comparisons, examining what different doctors do, but these efforts often miss what patients experience,” said Lorraine Kelley-Quon, MD, MSHS, FACS, FAAP, a pediatric surgeon at Children’s Hospital Los Angeles (CHLA) and Associate Professor of Clinical Surgery at the Keck School of Medicine of the University of Southern California (USC).

“We wanted to look at how many pills adolescent patients are using after surgery and how many pills they are prescribed,” she added.

Kelley-Quon and her team surveyed surgeons, residents, fellows, and advanced practice providers at CHLA about their prescribing behavior. Providers across specialties and roles were given scenarios of various procedures and asked how many opioid pills they would prescribe. These data were compared to the number of pills adolescents self-reported using after past surgeries. The article was published in the Journal of Surgical Research.

Kelley-Quon is a past recipient of the KL2 Mentored Career Development award from SC CTSI, a team-based research training that has enabled her to guide this project. The KL2 program provides protected research time for clinicians and allows scholars to conduct multidisciplinary projects and focus on designing, conducting, and analyzing clinical studies in a team-based setting.

The research shows that across a range of common procedures—from tonsillectomies and knee arthroscopies to complex spinal fusions—prescribers frequently estimated patients’ opioid use incorrectly. Prescriptions by attending surgeons more closely approximated how many pills patients reported taking. However, trainees, including residents and fellows, tended to under-prescribe opioids, as did pediatric surgeons.

“Under-prescribing by trainees could be due to the increased emphasis on opioid stewardship in recent education but also their lack of experience,” said Emma Kirkpatrick, first-coauthor and fourth-year medical student at the Keck School of Medicine of the University of Southern California. “Trainees are rotating services and not able to follow up with patients, so they aren’t getting as much feedback from patients.”

Orthopedic and cardiothoracic surgeons were more likely to overestimate opioid use.

“We are not pointing fingers or placing blame on specific departments,” Kirkpatrick added. “Our goal was to gather information that could help improve opioid prescribing practices across different surgical specialties.”

A promising outcome from the survey is that surgeons reported a willingness to adjust course on prescribing opioids. Nearly 89 percent of respondents said they would alter their prescribing procedures after seeing the patient-reported data. The study could help scientists develop more patient-centered strategies for managing post-surgical pain.

In the next stage of her research, Kelley-Quon is partnering with Dr. Mark Bicket at the University of Michigan to conduct a clinical trial comparing how well two pain control methods help patients recover at home after surgery. Funded by the Patient-Centered Outcomes Research Institute (PCORI), the CARES for Kids (Comparing Analgesic Regimen Effectiveness and Safety After Surgery for Kids) study will enroll 900 adolescents and young adults, randomly assigning them to be prescribed either a low-dose opioid or a non-opioid pain medication following common procedures. The researchers will follow up with patients up to one year after their surgery to assess patient-reported outcomes such as pain reduction after surgery, side effects and non-medical opioid use.

“It's important to ask families not only how many opioid pills they’re using after surgery, but also questions such as how satisfied they are with their pain control and whether their child is able to resume their normal activities,” Kelley-Quon said. “We are looking at different metrics to capture that information, asking which measurement tools would be the best ones to use and expand upon. This could give us greater sensitivity and specificity as to what moves the needle for better pain control.”

Focus group quotes and articles she published during her KL2 training provide a foundation for Kelley-Quon’s latest research. She notes her long-term goal is to help integrate more patient voices into clinical decision-making.

“Providers shouldn't only look to each other for standards of opioid prescribing,” said Kelley-Quon. “They should also engage their patients. They should have a mechanism to follow up with their patients and see how many opioid pills they're using. This could provide quality improvement for an individual surgeon, a division, or an entire department, depending on the scope of resources. But it’s also as easy as asking how many pills are used and tracking it individually for your patients.”