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FORT LAUDERDALE, Fla. -- A treatment strategy reserving opiates for breakthrough pain in pediatric patients after surgery appeared to be as effective in pain control as starting with opiate-acetaminophen combinations, researchers reported here.

Return to the hospital or to the emergency department for pain within 7 days of discharge and hospital length of stay were all similar between the patients who were given single-agent opiates only for breakthrough pain and those patients given a combination of opiates and acetaminophen from the start, said Muhammad Aishat, BS, a medical student at the University of North Texas Health Science Center/Texas College of Osteopathic Medicine in Fort Worth.

In the retrospective, single-institution study reported at the annual meeting of the American Academy of Pain Medicine, the research team identified 12,424 patients who underwent 13,646 surgical procedures from 2018 to 2020 at the Cook Children's Medical Center in Fort Worth. The pediatric patients were stratified by pain management schedule after the procedures:

• Non-steroidal anti-inflammatory drugs (NSAIDs) only: starting on ibuprofen, followed 6 hours later by acetaminophen, and then repeated cycles switching back and forth between the agents
• Combination treatment: starting with either hydrocodone/acetaminophen or oxycodone/acetaminophen for pain control upfront

Aishat told MedPage Today that if there was breakthrough pain on the NSAID schedule, then opiates (usually oxycodone) would be administered. "To the best of our knowledge, this is the first study of its kind to examine these outcomes in pediatric patients," he said.

Study co-author Alicia Segovia, MS, a medical student at the University of North Texas Health Science Center/Texas College of Osteopathic Medicine, who delivered the oral poster presentation, reported that the center's quality improvement initiative for opioid discharge guidelines resulted in an increase in single-agent opioid prescriptions for all surgical departments included in the study.

"The use of a multidisciplinary stewardship committee to implement prescribing guidelines for pediatric populations is an important component to promote safer and more efficacious opioid prescribing practices," she said.

Aishat said that the current recommended strategy switching back and forth between NSAIDs is done with the idea of reducing stress on the kidneys and on the liver. He said that the NSAIDs schedule aimed at lowering pain levels to 3 on a 10-point scale; breakthrough pain medication was delivered if the patient indicated pain reached a level of 7 or greater.

"We found there was no difference in outcomes – including length of stay in the hospital -- if opiates were withheld until breakthrough pain occurred," Aishat said.

In commenting on the study, Kellie Marie Jaremko, MD, PhD, an anesthesiologist at Johns Hopkins University in Baltimore, told MedPage Today that she tends to use a similar schedule for surgical pain relief for her surgical patients, although most of her patients are adults or adolescents.

"When using the single-agent strategy, you have to make sure that the patients doesn't go over their dose of Tylenol. But the idea is that you would use the anti-inflammatory agents to provide around-the-clock pain control, reserving the opiates until they are needed," she said.

"We really want to reduce opiates, especially in children, where we are concerned about the side effects of these drugs on the developing brain and possibly the risk of addiction beginning at a younger age," Jaremko said.

"However, uncontrolled pain is also a problem," she cautioned. "We have to make sure we don't swing the pendulum too far, and we are careful in optimizing as many non-opioids as possible and monitoring them closely to get them through their recovery."

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