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Opioid and Methadone Prescribing for Infants with Surgical Management of Congenital Heart Disease

Rabab M Barq1,2, Shadassa Ourshalimian3, Olivia A Keane3,4

  • 1Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #100, Los Angeles, CA, 90027, USA. rbarq@chla.usc.edu.

Pediatric Cardiology
|November 7, 2025
PubMed

Insights

Infants needing methadone treatment after heart surgery often have prolonged opioid exposure. Lower-risk infants (RACHS-2 score 1) with extended opioid use were more likely to receive methadone, indicating a need for targeted opioid stewardship.

Area of Science:

  • Pediatric Surgery
  • Neonatal Care
  • Pharmacology

Background:

  • Opioids are frequently used post-surgery for congenital heart disease (CHD) in infants.
  • Prolonged opioid exposure can lead to physiological dependence, necessitating methadone treatment.
  • The Risk Adjustment for Congenital Heart Surgery-2 (RACHS-2) score predicts surgical mortality risk.

Purpose of the Study:

  • To investigate the association between RACHS-2 scores and the likelihood of methadone treatment in infants undergoing CHD surgery.
  • To explore the relationship between postoperative opioid exposure duration and methadone treatment initiation.
  • To identify patient subgroups that may benefit from enhanced opioid stewardship programs.

Main Methods:

  • Retrospective cohort study of infants (<1 year) undergoing CHD surgery (2016-2022) at 48 US children's hospitals.
  • Infants were categorized by RACHS-2 score (1=lowest, 5=highest risk).
  • Multivariable logistic regression analyzed associations between opioid exposure, RACHS-2 scores, and methadone treatment, including interaction effects.

Main Results:

  • Higher RACHS-2 scores correlated with longer postoperative opioid exposure (p<0.001).
  • For opioid exposure <17 days, higher RACHS-2 scores predicted increased methadone probability.
  • After 17 days of opioid exposure, infants with the lowest RACHS-2 score (1) showed the highest methadone probability.
  • Methadone treatment was linked to longer length of stay, ventilator days, and total parenteral nutrition (TPN) days.

Conclusions:

  • RACHS-2 scores are associated with postoperative methadone treatment likelihood, particularly in the early postoperative period.
  • Methadone treatment is independently associated with adverse short-term outcomes.
  • Infants with lower RACHS-2 scores and prolonged opioid exposure represent a key subpopulation for targeted opioid stewardship interventions.

Keywords:
Congenital heart diseaseInfantsOpioidsPainPharmacologyRACHS-2

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