Abstract

NM-242

Medication violations and discontinuation of opioid therapy in a pediatric chronic pain clinic

Cappuccio E, Tumin D, Wrona S, Smith T, Veneziano G, Tobias J, Bhalla T
Nationwide Children's Hospital, Columbus, OH, USA

Introduction: Since the late 20th century, chronic opioid therapy has been a mainstay in the management of chronic pain. However, potentially fatal risks associated with long term opioid use has led to increasing awareness of opioid misuse, abuse, and diversion (MAD). As opioid use among adolescents increases, judicious prescribing and prevention of opioid MAD is of special concern in this pediatric population. At our outpatient chronic pain clinic, we are implementing a process of routine monitoring for opioid MAD, and escalation of monitoring or cessation of opioid therapy when MAD is suspected. To better define the warning signs that could be incorporated in this process, we retrospectively reviewed cases where opioid therapy was discontinued due to suspected opioid MAD in patients seen by the chronic pain service.

Methods: A retrospective chart review was conducted to identify patients who were seen in the Comprehensive Pain Clinic at Nationwide Children's Hospital and had opioid therapy discontinued in 2015-2016 for reasons involving suspected or confirmed opioid MAD. Medical records were reviewed from the time of chronic pain service intake until the time opioid therapy was discontinued. Minor violations (e.g., missed pill counts) and major violations (e.g. negative urine drug screen [UDS] for opioids) were extracted from patients’ medical record (Table).

Results: Of 79 cases where opioid therapy was discontinued during the study period, the pain clinic team identified 8 patients (2 male/6 female, ages 13-23 years) whose opioid discontinuation was related to documented or suspected opioid MAD. Of these cases, only 2 patients had opioid MAD explicitly documented as the reason for opioid therapy discontinuation. Five of the 8 patients had minor violations documented, while 3 had major violations (caregiver presenting impaired, UDS negative for opioids, UDS positive for illicit substance, concerning behaviors of the patient, and concerned medical provider—and in 1 case a pharmacist explicitly concerned about a caregiver’s behaviors). Only 2 patients had repeated medication violations noted (timeline shown in the Figure), although both patients continued opioid therapy for >1 year after a pattern of multiple violations became apparent.

Discussion: There is a large variation in the extent of documentation amongst providers. While missing or canceling 2 or more appointments was the most commonly documented violation, a discrepancy on a UDS was the reason documented for discontinuation of opioid therapy in both patients overtly involved in opioid MAD. Interestingly, the time of first documented violation to discontinuation opioid therapy was greater than 1 year, demonstrating great room for improvement in provider compliance.