Pediatrics: Enhancing Post-Op Recovery and Reducing Opioid Use with Non-Opioid Protocols

By: Erin Dale, P.N.P./F.N.P., Rady Children's Hospital - San Diego

Published: 11/20/2022

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Sponsored by Pacira. AORN does not endorse any commercial company's products or services mentioned in this article.

Erin Dale is a Family Nurse Practitioner working with the Care Redesign program at Rady Children's Hospital San Diego. She works on quality initiatives to improve patient outcomes with an emphasis on health literacy and patient education.

Patients of all ages are often prescribed opioids for post-op recovery, however, we know that minors are at increased risk of misusing them. Research shows that those aged 18-25 were most likely to misuse opioids in 2020, and prescription drug misuse in adolescents ages 10-14  increased the same year according to a study funded by the National Institute on Drug Abuse (NIDA). Even further, studies have shown that opioids can be attributed to 50% of postsurgical respiratory failure events in children and may also hinder recovery, extend hospital stay, and negatively impact both patient and parent experience.

In addition to these startling statistics, opioids can cause an array of side effects:

  • Sleepiness
  • Itching
  • Urinary retention
  • Nausea
  • Constipation
  • The risk for addiction or dependence

All of these factors contribute to a recent shift by healthcare providers to develop opioid-sparing approaches, especially for vulnerable patients such as children. At Rady Children’s Hospital, my team and I are proactively working to minimize opioid exposure for our pediatric patients following surgery. As substance abuse disorders remain a community concern and the opioid epidemic continues to garner national headlines, our team had a keen eye on seeking out effective alternatives. Fortunately, with the availability of innovative non-opioid options to manage postsurgical pain, our team has been able to successfully reduce, or even eliminate entirely, the need for our pediatric patients to take opioids, while still providing effective pain relief.

The Key to Reducing Opioid Use

Our success has stemmed from implementing a multimodal, non-opioid approach to manage pain in our practice. Long-acting local analgesics have become an essential part of multimodal pain management regimens for their ability to help limit opioid use while ensuring sufficient pain control. Through these methods, for surgeries ranging from Nuss procedures to spinal fusions and hip replacements, our team has made statistically significant strides in reducing opioid use and providing an overall enhanced recovery experience from start to finish.

The incorporation of EXPAREL® (bupivacaine liposome injectable suspension) into our pain management protocol has been a game changer in allowing us to decrease opioid use postoperatively, both with lower standard dosing of postoperative IV opioids and lower doses of oral opioids when transitioning to oral medications. EXPAREL is a long-acting local analgesic that is injected directly into the surgical site and uses proprietary multivesicular liposome (pMVL) technology to provide prolonged pain control. After injection, bupivacaine is released over time, providing pain relief for the first few – typically most painful – days after surgery.

Results to Remember

As a pain nurse practitioner, I have seen firsthand the encouraging results multimodal pain methods have afforded our practice and, more importantly, our patients:

  • In addition to opioid minimization, patients are up and moving around sooner, which is vital for procedures associated with multiple day hospital stays.
  • We have also noted a reduction in “button presses” from patients requesting rescue pain medication after surgery.
  • Patients are reporting reduced post-op pain scores.
  • By the time long-acting analgesics wear off, a lot of healing has taken place, and patients’ pain remains well controlled.

Results like these have driven my team and I to incorporate non-opioid protocols, including EXPAREL, in as many cases as possible, with continued positive outcomes.

The ability to locally target pain, minimize opioid use and unnecessary opioid-related side effects, and enhance overall recovery demonstrates important momentum in the field of surgical pain management. Young patients can be especially susceptible to the downstream consequences of opioids. Embracing non-opioid options and educating patients – and their parents – about these options can allow us as providers to enhance our practices and optimize the surgery and recovery experience for our patients.

Erin Dale is a consultant of Pacira BioSciences, Inc.

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated for single-dose infiltration in patients aged 6 years and older to produce postsurgical local analgesia and in adults as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

EXPAREL should not be used in obstetrical paracervical block anesthesia.

In studies in adults where EXPAREL was injected into a wound, the most common side effects were nausea, constipation, and vomiting.

In studies in adults where EXPAREL was injected near a nerve, the most common side effects were nausea, fever, and constipation.

In the study where EXPAREL was given to children, the most common side effects were nausea, vomiting, constipation, low blood pressure, low number of red blood cells, muscle twitching, blurred vision, itching, and rapid heartbeat.

EXPAREL can cause a temporary loss of feeling and/or loss of muscle movement. How much and how long the loss of feeling and/or muscle movement depends on where and how much of EXPAREL was injected and may last for up to 5 days.

EXPAREL is not recommended to be used in patients younger than 6 years old for injection into the wound, for patients younger than 18 years old for injection near a nerve, and/or in pregnant women.

Tell your health care provider if you or your child has liver disease, since this may affect how the active ingredient (bupivacaine) in EXPAREL is eliminated from the body.

EXPAREL should not be injected into the spine, joints, or veins.

The active ingredient in EXPAREL can affect the nervous system and the cardiovascular system; may cause an allergic reaction; may cause damage if injected into the joints; and can cause a rare blood disorder.

For more information please visit www.EXPAREL.com or CALL 1-855-793-9727. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call  1-800-FDA-1088.
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