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Otolaryngology practice patterns in pediatric tonsillectomy: The impact of the codeine boxed warning
Julie L Goldman1, Craig Ziegler2, Elizabeth M Burckardt1
1Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders, University of Louisville School of Medicine, Louisville, Kentucky, U.S.A.
Insights
Pediatric otolaryngologists significantly reduced codeine prescriptions after a boxed warning. This led to decreased overall narcotic use without increasing pain or complications, suggesting safer pain management practices post-tonsillectomy.
Area of Science:
- Pediatric Otolaryngology
- Pharmacovigilance
- Pain Management
Background:
- Codeine use in pediatric post-tonsillectomy patients is subject to safety warnings.
- Otolaryngologists' adherence to these warnings impacts practice patterns.
- Understanding adherence is crucial for optimizing pediatric pain management.
Purpose of the Study:
- To assess otolaryngologist adherence to the codeine boxed warning in post-tonsillectomy care.
- To evaluate the impact of the warning on practice patterns and patient outcomes.
- To analyze prescription trends and complication rates before and after the warning.
Main Methods:
- Retrospective case series with chart review of 2,749 adenotonsillectomy patients (2010-2015).
- Stratification by date (pre/post-boxed warning) and practitioner type (academic vs. nonacademic otolaryngologists).
- Analysis of demographic data, surgical details, narcotic prescriptions, and complications; Fisher exact test used for significance.
Main Results:
- Codeine prescriptions decreased significantly, reaching zero sooner in academic otolaryngologists.
- A 5% decrease in discharge narcotic prescriptions was observed post-warning (P < .001).
- No significant difference in postoperative emergency department visits or pain-related complications was found.
Conclusions:
- Codeine use for pediatric post-tonsillectomy pain is now minimal following the boxed warning.
- Overall narcotic use decreased without a rise in adverse events.
- Further research should identify at-risk patients and optimal pain management strategies.
Objectives/Hypothesis:
To determine if otolaryngologists at a single children's hospital were adherent to the boxed warning for codeine use in post-tonsillectomy patients and the implications for practice patterns.
Study Design:
Case series with chart review.
Methods:
Charts from all patients undergoing adenotonsillectomy at a single children's hospital from January 1, 2010 through December 31, 2015 were analyzed and stratified according to date (pre- or post-boxed warning) and practitioner type (academic otolaryngologists [AO] vs. nonacademic otolaryngologists [NAO]). Demographic data, surgical technique, method of removal, narcotic prescriptions (dosage and drug), and complications were recorded. Fisher exact test was used to determine the level of significance in prescription rates pre- and postwarning. SPSS version 22 was used for statistical analysis, with P < .05 indicating statistical significance.
Results:
There were 2,749 children undergoing adenotonsillectomy during the study period, with 1,239 AOs and 1,510 NAOs. There was a distinct downward trend in codeine prescriptions before and after the warning, with the AO group reaching zero sooner than the NAO group. There was a 5% decrease in discharge narcotic prescriptions given postwarning (P < .001), but no significant difference in postoperative emergency department visits or pain-related complications when comparing the two time periods.
Conclusions:
Codeine use for management of pediatric post-tonsillectomy pain was essentially zero after issuance of the boxed warning. Total narcotic use decreased significantly without increase in pain- or medication-related complications. Future research should focus on identifying markers of increased susceptibility to adverse medication events and determining the safest options for pain management.
Level Of Evidence:
4. Laryngoscope, 128:264-268, 2018.
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