Saving Kids From Addiction: Shriners Children’s Sets Standards for Adolescent Opioid Use Post-Surgery

Opioids are powerful pain relievers commonly prescribed to high school athletes recovering from sports injuries. The goal for their use is to reduce pain and speed recovery. However, opioids are also highly addictive, and the amount prescribed for common surgical procedures varies significantly depending on the provider.

Too Many Pills, Too Little Data

“There are so many kids – football players, cheerleaders, baseball and volleyball players – excelling at various activities. They play hard, they get injured, they need surgery, and they're given opioids to manage pain,” said Sundeep (Sunny) Tumber, D.O., chief of pediatric anesthesia at Shriners Children’s Northern California.

“We hear these stories over and over again. Some kids receive too many pills, get hooked, and it becomes a near life sentence for them and their families,” Dr. Tumber added. “We have to break this cycle.”

While there are benefits for the use of appropriate opioid pain medicines, there are also risks. Opioids can cause serious side effects and lead to dependence, addiction and overdose. A nationwide survey commissioned by the American Society of Anesthesiologists found that while more than half of parents surveyed expressed concern their child may be at risk for opioid addiction, nearly two-thirds believe opioids are more effective at managing their child’s pain after surgery or a broken bone than non-prescription medication or other alternatives.

In 2018, over 10% of U.S. adolescents were prescribed opioids, most commonly for injuries, dental work or surgery, according to a report by the Centers for Disease Control and Prevention. A 2021 report released by the American Academy of Pediatrics highlighted the lack of national data on details about opioid prescriptions for children, adolescents and young adults.

Collaborating to Set Industry Standards

Recognizing the need for data to guide safe and effective opioid use in adolescent pain management, Dr. Tumber and colleagues from 10 other facilities within Shriners Children’s international healthcare system are conducting a comprehensive, three-year study. The goal is to standardize and optimize pain management protocols for opioid use after ACL surgery in adolescents and young adults.

“Establishing detailed protocols will ensure all staff are comfortable with pain management plans related to ACL surgery. This will reduce variability, improve patient safety and support evidence-based care,” said Lloyd Halpern, M.D., pediatric anesthesiologist at Shriners Children’s Spokane, another of the Shriners Children’s physicians participating in the study.

“Shriners Children’s is the largest provider of pediatric orthopedic healthcare in the world,” Dr. Tumber said. “We’re in a unique position to collaborate and develop protocols that will improve outcomes for our own patients, and that will also save countless young lives by shaping industry-wide best practices.

“Extra prescription opioids are a major source of misuse among high school students,” Dr. Tumber continued. “We want to ensure young patients aren’t in pain, but we also know that less exposure to opioids is better. This research is about finding that delicate balance.”

Advancing Alternative Pain Treatments

A key part of this research involves increasing the use of nonopioid pain treatments, such as nerve blocks, to manage pain during and after surgery.

Nerve blocks are highly effective at reducing pain during and after sports surgeries. However, its use among children and adolescent patients varies widely depending on the institution and the anesthesiologist’s level of expertise. At Shriners Children’s Northern California the use of nerve blocks is a standard practice strongly supported by pediatric anesthesiologists and surgeons.

Regional nerve blocks target pain in specific areas of the body, such as the hand, knee or foot. During a nerve block placement, the pediatric anesthesiologist uses an ultrasound to find the specific nerves that conduct pain signals from the injured area to the brain. While the patient is under anesthesia, the anesthesiologist uses a needle to approach the nerve and inject numbing medication around it. Depending on the type of numbing medication used,  the pain-limiting effects can last over three days after the surgery, a time when patient’s opioid requirements significantly drop.

“When regional nerve blocks are used to manage post-surgery pain effectively, patients don’t need to leave the hospital with a prescription for as many opioids,” Dr. Tumber explained. “Reducing the number of opioids prescribed makes our communities safer because it limits the availability of unneeded doses.”

For many years, Shriners Children’s Hawai`i has embraced a multi-modal approach to postoperative analgesia – a multidisciplinary approach to pain management after surgery that aims to reduce opioid use, improve recovery and reduce complications. In the last two years, it has committed to optimizing this.

“We strive for all patients to get acetaminophen before the start of surgery,” said Harlan Klein, M.D., chief of anesthesiology at Shriners Children’s Hawai’i, who is also participating in the study. “After surgery we order around-the-clock acetaminophen and NSAIDs – a class of drugs that can reduce pain and inflammation, and treat fevers for most of our surgical patients. Both strategies have been shown to decrease narcotic requirements post-operatively.”

“For our most painful surgeries, we do adductor canal blocks for our ACL reconstruction patients,” added Shriners Children’s Hawai`i anesthesiologist Brandi Blair, M.D. “In the past, they required patient-controlled anesthesia overnight after surgery. Today, many of our patients go home the same day."

Educating Families on Proper Opioid Use

The effort to reduce opioid use after ACL surgery in adolescents also includes efforts by a multidisciplinary team of Shriners Children’s surgeons, anesthesiologists and researchers who are standardizing patient education materials to ensure teenagers and families have clear direction about when and how to use opioids, how to dispose of unused doses, and how to recognize symptoms of opioid overdose.

“Our goal is to conduct research, review the data, and develop protocols to manage pain effectively without over-prescribing opioids, which can lead to addiction. Educating providers, patients and families is a key part of this effort,” Dr. Tumber said.

Texting and Timing

In the future, patients and families will contribute to the study by using a text-based app called RxCheckIn, which tracks patient progress and opioid use. The study, focused on analyzing opioid prescribing practices for arthroscopic knee surgeries and spine surgeries, will start early in 2025.

Shriners Children’s Continued Commitment to Quality

The industry-leading opioid research project is funded by Shriners Children’s as one of its quality improvement initiatives, which are designed to develop new tools, processes and programs to improve pediatric care. All Shriners Children’s locations in the United States that provide care to sports medicine patients will be participating in this initiative. The project is led by Dr. Tumber and De-An Zhang, M.D., FASA, at Shriners Children’s Southern California.

“We are excited about gaining real-time data on opioid usage after these painful orthopedic procedures so we can predict how many opioid pills, if any, a patient will need to effectively manage pain after surgery,” said Dr. Lloyd Halpern, from Shriners Children’s Spokane. “Shriners Children’s is uniquely positioned to lead this effort. We are committed to reducing opioid exposure for our patients and our communities.”