How doctors collaborated with researchers to minimize risks for childhood patients after tonsillectomies.
In 2013 the Food and Drug Administration began requiring that a “black box warning” be added to the labels of drugs containing codeine, advising physicians not to give the narcotic pain medications to children after they have their tonsils removed. A black box warning is the strictest FDA warning, and was issued after the deaths of three children who had been prescribed the medication following tonsillectomies.
“Even with the warning, many surgeons continue to prescribe narcotics to children after tonsillectomies,” says Anna Grosz, MD, a Kaiser Permanente otolaryngologist in Portland, Oregon. In this interview, Dr. Grosz explains how she partnered with researchers from the Kaiser Permanente Center for Health Research to reduce the issuing of such prescriptions.
Doctors usually want to see the evidence before we make a change. At Kaiser Permanente, we have an advantage because we are part of an integrated system and we’re used to relying on evidence-based medicine and asking our doctors to change their practice when we learn of new evidence.
When I heard about the FDA warning, I felt strongly that we needed to make changes in our practice, so I did some research to see if there were any studies about using narcotic alternatives to help control pain in kids after they have a tonsillectomy. I found a couple of studies where doctors had success using alternative pain medications, so I approached the other 15 surgeons in the otolaryngology department to see if they were willing to try non-narcotic pain medications.
A few of my fellow surgeons were concerned that these medicines wouldn’t be strong enough to control the pain, others were worried that these medicines carried a higher risk of bleeding. I suggested that we try out the alternative medications to see how they worked and if there were any downsides.
Once we made the switch, prescriptions for narcotics after children’s tonsillectomies fell from 82 percent to 15 percent. We saw no differences in bleeding, and in most cases, the pain was well-controlled. A nurse called parents within a week of surgery to ask about pain, bleeding, dehydration, sleep and other problems. If the child’s pain wasn’t controlled with the non-narcotic medication, we ordered a narcotic, but that only happened in 11 percent of the cases. Some surgeons did prescribe narcotics to children right after surgery, but this only happened in 4 percent of the cases.
Researchers from the Kaiser Permanente Center for Health Research helped me design the study. They also pulled the data from our electronic medical record. The reason our new protocol worked so well was that we made it easier for surgeons to prescribe the non-narcotic pain medications. Our electronic medical ordering system used to allow surgeons to select the pain medication they wanted after tonsillectomy, but now it defaults to automatically select non-narcotic medications for children. If surgeons want to prescribe narcotics they still can, but they have to override the automatic default.
We prescribe ibuprofen and acetaminophen alternating every three hours. These medications are safer for kids, and in many cases they actually work better. If you give your child a narcotic, it’s a respiratory depressant. If the child has already had anesthesia, this is a double whammy for their respiratory system. Many kids complain about anxiety after receiving narcotics. There are so many reasons to avoid giving narcotics to kids.
The black box warning applies only to this surgery for children, but we have also cut back on narcotic use in other surgeries. I do a lot of ear surgery in kids and adults, and in most of those surgeries I start out by prescribing non-narcotic pain medications. That’s usually enough to control the pain. I have colleagues who have switched to mostly non-narcotic pain medications after sinus surgery.
Of course, there are many surgeries where patients need narcotics for pain control. One example is adult tonsillectomies. Adults take longer to recover and they complain of more pain when having their tonsils out, so we prescribe narcotic pain medications for them.
For the most part, parents are happy that their kids are not receiving opioid narcotics. When we explain that ibuprofen and acetaminophen control the pain in most kids, they are willing to try these medications first before getting a prescription for codeine. We still write prescriptions for the ibuprofen and acetaminophen because many parents feel better if they have a prescription, but they could also get these medications from the drugstore without a prescription.
We have the evidence that this new protocol works, and we have published our findings in a scientific journal. Now I’m working with several Kaiser Permanente regions to implement the protocol throughout our system.