Published: July 3, 2024

Insights into Post-Tonsillectomy Pain Management from the Reg-ent Registry

An exploration of post-tonsillectomy pain management in children and adolescents using data available in Reg-ent.

Shutterstock 2217531899Over the past eight years, the Reg-ent Clinical Data Registry has amassed data from 10 million patients across 50 million encounters. The Academy’s Reg-ent team is currently delving into Reg-ent's data studio to begin assessing adherence to clinical practice guidelines (CPGs) published by the Academy. Here are the results of our analysis using data available in Reg-ent to evaluate whether post-tonsillectomy pain management in children and adolescents in clinical practice adheres to previously published guidance from the Academy.

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Introduction

Tonsillectomy is among the most commonly performed pediatric surgical procedures in the United States, second only to myringotomy with tube insertions.1 Updated in 2019, the Academy's CPG “Tonsillectomy in Children” defines it as, “a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall.”2 This surgery addresses recurrent throat infections and obstructive sleep apnea and can enhance overall quality of life.2

The Academy has published several articles and CPGs that highlight the importance of evidence-based quality improvement in managing pediatric patients undergoing a tonsillectomy and provide clear and actionable recommendations to implement these opportunities in clinical practice. The guidelines provide evidence and recommendations that support tonsillectomy as an effective treatment for pediatric patients.

Here, we present a use-case for how practices in Reg-ent can use the data available to them in the registry’s repository to explore topics of clinical interest. We selected a specific topic of interest to our members for the current analysis: pain management during the post-tonsillectomy period in pediatric patients.

After a tonsillectomy, patients usually experience moderate to severe pain and difficulty swallowing for the first few hours—but this pain can last 7 – 10 days.3 The Academy’s CPG “Tonsillectomy in Children” (updated in 2019) strongly recommends against prescribing opioids post-tonsillectomy for patients younger than 12 years, and recommends instead the use of ibuprofen, acetaminophen, or alternating both for pain control.2 Although opioids are known for their potent analgesic ability, they possess risks such as nausea, opioid-induced respiratory depression, drug interactions, and abuse potential.4 Despite the risks of prescribing opioids, significant knowledge gaps have been identified regarding prescription of opioid versus non-opioid medication.3

Materials and Methods

The Reg-ent team analyzed initial population data from our data set, focusing on tonsillectomy cases in patients aged 4 – 18 years. In compliance with HIPAA policies, we omitted patients younger than 4 years old. The remaining data was analyzed to identify which patients were prescribed opioids and non-opioids during the five days post-operation. For non-opioid prescriptions, we grouped nine medication types, including analgesics, NSAIDs, anesthetics, and combination drugs. Anesthetic drugs prescribed on the day of the procedure, like hydromorphone and fentanyl, were excluded. For opioid prescriptions, we identified seven drug types, including morphine, codeine, and oxycodone.

Results

In total, we evaluated 13,831 patients who were prescribed opioid, non-opioid or a combination of medications for pain management within five days of their tonsillectomy. This initial analysis included data from various providers, introducing potential variability that might affect trends in medication usage. All data on opioid, non-opioid, and combination medications were captured and analyzed. Among the 13,831 patients, we identified 8,454 patients who received an opioid prescription, while 5,377 patients received a non-opioid prescription. Acetaminophen-hydrocodone was the most commonly prescribed drug including an opioid, whereas ibuprofen was the predominant non-opioid for pain management. The data, spanning 2019 to 2023, showed a decline in opioid prescriptions from 2019 (72.6%) to 2021 (59.7%), a slight rise in 2022 (62.7%), and the lowest rate in 2023 (56.3%).

To explore prescription trends, we further analyzed the data based on geographical location (state and region) and other demographic characteristics such as age, ethnicity, race, and gender. Demographic analysis revealed that 58% of male patients aged 4 – 18 years were prescribed opioids, compared with 64% of female patients. Opioid prescriptions were highest in children aged 15 – 18 (82%) and lowest in those aged 4 – 8 (50%). When looking at both genders, 31% of four-year-olds were prescribed opioids; this amount gradually increased with age, reaching 86% by the age of 18 years. For both genders, 18-year-olds had the highest opioid prescription rate.

Ethnically, Hispanic or Latino patients had lower opioid prescription rates (40%) compared with non-Hispanic patients (55%) and other ethnic groups (74%). Further analysis according to race showed that American Indian and Asian populations had opioid prescription rates of 72% and 52%, respectively, though there were fewer of these patients represented in the data. In contrast, Black patients (43%) and patients of other racial groups (29%) were prescribed at relatively lower rates than White patients (63%).

Using the data, we were also able to explore prescription trends geographically. Opioid prescription rates were highest in the midwest (96%), followed by the west (69%), southeast (56%), southwest (45%), and northeast (42%).

Finally, we looked at trends in opioid prescription rates over time. In 2019, 72.8% of our study population was prescribed opioids, with oxycodone and acetaminophen-hydrocodone combination drugs being the most common. Non-opioid prescriptions, such as ibuprofen or acetaminophen, accounted for 26.2% in the same year. This trend shifted by 2021, with opioid prescriptions decreasing to 59.7% and non-opioid prescriptions rising to 40.3%. By 2023, opioid prescriptions dropped even lower, reaching their lowest point at 56.3% since the 2019 CPG publication.

Discussion and Conclusions

Over the past 20 years, opioid prescriptions have increased at an alarming rate. A significant contributor to the excess opioid supply has been attributed to post-operative opioid prescriptions.5 The current study was initiated to observe trends in the frequency and volume of opioid prescriptions in the five years since the updated CPG “Tonsillectomy in Children” was published. Based on our results, we expect that the CPG has contributed to the observed decrease in the rates of post-tonsillectomy opioid prescription in the pediatric population.

A more extensive study is warranted to highlight the extent of the improvement and account for the continued prescription of opioids by some providers that we observed here. This continued reliance on opioids by some providers could relate to prior studies showing that ibuprofen and acetaminophen may be less effective for pain management or could potentially worsen the frequency and severity of post tonsillectomy than hemorrhages than opioids.6 However, the 2019 CPG found that the benefits of administering ibuprofen and acetaminophen, or a combination outweigh these factors. Given the CPG’s recommendations and our current findings, we strongly recommend the promotion and continuation of clinician education regarding limiting the prescription of opioids in pediatric patients post-tonsillectomy.2

Using Reg-ent data, providers can perform larger studies to study the risks and benefits of opioid versus non-opioid medications for pain management after tonsillectomy and other otologic procedures. Such extensive studies would provide our specialty with a better understanding of the appropriate dosages for our patients.6

References

  1. Cullen KA, Hall MJ, Golosinskiy A. “Ambulatory surgery in the United States.” 2006. National Health Statistics Reports (2009)
  2. Mitchell, R. B., Archer, S. M. “Clinical Practice Guideline: Tonsillectomy in Children (Update).” Otolaryngology–Head and Neck Surgery (2019) doi:10.1177/0194599818801757
  3. Amin, S. N., Thompson, T. “Reducing Pediatric Post-Tonsillectomy Opioid Prescribing: a quality Improvement initiative.” Otolaryngology–Head and Neck Surgery (2023) https://doi.org/10.1002/ohn.534
  4. Chua KP, Brummett CM, Conti RM, Bohnert AS. “Opioid prescribing to US children and young adults in 2019”. Pediatrics (2021) doi:10.1542/peds.2021-051539
  5. Calcaterra, SL, Yamashita, TE, Min, SJ, et al. "Opioid prescribing at hospital discharge contributes to chronic opioid use." Journal of General Internal Medicine (2016)
  6. O'Brien DC, Zalzal H, Adkins D, Gates C, Gonzaga J, Sanders L, Carr MM, Kellermeyer B. “Standardization and Reduction of Narcotics After Pediatric Tonsillectomy.” Otolaryngology–Head and Neck Surgery. (2021) doi: 10.1177/0194599820946274