Video Abstract

Video Abstract

Close modal
BACKGROUND

Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years.

METHODS

We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with ≥1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by ≥1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the ≥95th percentile.

RESULTS

Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had ≥1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of ≥50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by ≥1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions.

CONCLUSIONS

Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.

What’s Known on This Subject:

Recent national data are lacking on the prevalence of dispensed opioid prescriptions among US children and young adults; the frequency of high-risk prescriptions that increase risk of adverse events, including overdose; and the prescribers who account for the most prescriptions.

What This Study Adds:

Of 4 million opioid prescriptions dispensed to US patients aged 0 to 21 years in 2019, 46% were high risk. Dentists and surgeons wrote 61% of prescriptions. High-volume prescribers with prescription counts at the ≥95th percentile wrote 53% of prescriptions.

Ensuring the safety and appropriateness of pediatric opioid prescribing, defined as prescribing to children aged 0 to 17 years and young adults aged 18 to 21 years, is an important clinical and public health goal. In the short-term, prescription opioid exposure increases the risk of opioid-related adverse events, including overdose.16  In the long-term, this exposure is associated with increased lifetime risk of substance use disorders in adolescents and young adults.79  Pediatric opioid prescribing also has spillover effects because opioids prescribed to children and young adults can be misused by relatives and friends.1012 

Recent national data are lacking on the prevalence of dispensed opioid prescriptions among US children and young adults, the frequency of high-risk prescriptions that increase the risk of opioid-related adverse events, and the prescribers who account for the most pediatric opioid prescriptions and high-risk prescriptions. In previous studies, researchers have reported recent trends in opioid prescribing to children by using commercial insurance claims and data from individual states,1315  but the generalizability of findings is unclear. Timely national data on pediatric opioid prescribing could inform the design of initiatives to improve this prescribing. For example, if a small group of prescribers accounts for most high-risk prescribing, initiatives targeting these prescribers may be warranted.

Using a national prescription-dispensing database, we assessed the prevalence, safety, and prescribers of opioid prescriptions dispensed to US children and young adults in 2019. To our knowledge, we provide the most recent and complete data on US pediatric opioid prescribing to date in this study.

In January 2021, we conducted a cross-sectional analysis of the 2019 IQVIA Longitudinal Prescription Database. This database contains a record for every prescription dispensed in 2019 from 92% of US retail pharmacies (eg, chain pharmacies and food store pharmacies), 70% of mail-order pharmacies, and 70% of pharmacies in long-term care facilities. In the database, dispensing from pharmacies that serve only patients from specific hospitals or health systems (eg, those affiliated with Kaiser Permanente) is not captured. Data elements include drug name, dosing (eg, days supplied), prescriber identifiers and specialty, patient identifiers and characteristics, and method of payment (commercial, Medicaid or other non-Medicare public insurance [eg, state public insurance programs], cash, and Medicare). Data on patient income, race, ethnicity, and prescription indication are not included. As needed, we used data from 2018 when a 90-day look-back period was required for prescriptions in early 2019.

Analyses assessed dispensing of opioid analgesics and benzodiazepines included in IQVIA’s market definition of these drug classes (Appendix 1). The former excluded opioid cough-and-cold medications and buprenorphine formulations approved for opioid use disorder. Because data were deidentified, the Institutional Review Board of the University of Michigan Medical School exempted this study from review.

Analyses were conducted at the prescription rather than patient level. We included opioid prescriptions dispensed in 2019 to children and young adults aged 0 to 21 years who lived in one of the 50 US states or the District of Columbia. We chose this age range to capture the population seen by pediatric providers.16  We did not include prescriptions from veterinarians. We excluded prescriptions for injectable opioid formulations and prescriptions with missing or potentially invalid dosing information, defined as days supplied ≤0, days supplied >90, or quantity ≤0.

On the basis of dispensing totals and population denominators from the 2019 American Community Survey,17  we calculated the proportion of US children and young adults with ≥1 dispensed opioid prescription in 2019 (see Appendix 2 for details). We repeated analyses by age group, sex, and Census region of patient residence.

We calculated performance on 6 metrics of high-risk prescribing:

  • Metrics 1 and 2: Proportion of dispensed opioid prescriptions to opioid-naive patients exceeding a 3-day or 7-day supply. The Centers for Disease Control and Prevention opioid prescribing guidelines indicate a 3-day supply usually suffices for acute pain, whereas supplies exceeding 7 days are rarely necessary.18  These thresholds were largely based on data from older adults but may also be reasonable for children and young adults. For example, in previous studies, opioid consumption after common pediatric surgeries was typically ≤3 days.11,19,20  Because data lacked information on indication, we used opioid-naive status as a surrogate for acute pain. In support of this approach, 75.4% of prescriptions to opioid-naive patients in this study were written by dentists, surgeons, or emergency medicine physicians (Appendix 3). Following a National Quality Forum–endorsed quality measure, we defined opioid-naive status as the absence of dispensed opioid prescriptions in the 90 days before dispensing.21 

  • Metrics 3 and 4: Proportion of opioid prescriptions dispensed to young children aged 0 to 11 years that were for codeine and proportion of these prescriptions that were for tramadol. In 2017, the US Food and Drug Administration contraindicated codeine and tramadol use in young children owing to reports of fatal overdose in this age group.22 

  • Metric 5: Proportion of opioid prescriptions dispensed to adolescents and young adults aged 12 to 21 years with daily dosages of ≥50 morphine milligram equivalents (MMEs). MMEs are a standardized measure of opioid dosage; 50 MMEs corresponds to 10 pills containing 5 mg hydrocodone.23  We calculated daily MMEs by multiplying strength, quantity, and published MME conversion factors,23  then dividing by days supplied. The 50-MME threshold derives from the Centers for Disease Control and Prevention guidelines.18  Although this specific threshold has not been tested in adolescents and young adults, overdose risk in this population increases as daily opioid dosage rises.3  We did not assess this metric for young children because we lacked information on weight, which affects risks associated with any given dosage level.24  In contrast, most opioid prescriptions to adolescents and young adults use weight-invariant adult dosing. For example, mean weight of adolescents aged 14 years is ∼50 kg.25 

  • Metric 6: Proportion of opioid prescriptions dispensed to adolescents and young adults that overlapped with a benzodiazepine prescription for ≥1 day. We included this metric because concurrent opioid and benzodiazepine exposure greatly increases overdose risk in adolescents and young adults.3  To calculate the metric, we converted opioid and benzodiazepine prescriptions to periods of exposure that would occur if patients took medications as prescribed.3  This period began on the dispensing date and ended on the dispensing date plus days supplied minus 1. If the exposure period for an opioid prescription overlapped with that of a benzodiazepine prescription, the opioid prescription was included in the numerator.

We calculated the proportion of all prescriptions classified as high risk by ≥1 metric. For each metric, we calculated performance by demographic characteristics. Using logistic regression with Huber-White robust standard errors clustered at the patient level, we assessed which characteristics were associated with performance. We calculated average marginal effects (AMEs), or the difference in the probability of outcomes if all patients were in a particular demographic category versus the baseline category.26 

In prescriber analyses, we excluded prescriptions with missing prescriber identifiers. Of the remaining prescriptions, we calculated the proportion written by each specialty. To assess the degree to which pediatric opioid prescribing and high-risk prescribing is concentrated, we ranked prescribers by the number of opioid prescriptions dispensed to children and young adults in 2019 and identified those with prescription counts at the ≥95th percentile. We calculated the proportion of all prescriptions and high-risk prescriptions accounted for by these high-volume prescribers versus other prescribers. Among prescriptions from high-volume prescribers and other prescribers that were eligible for each metric of high-risk prescribing, we calculated the proportion classified as high risk by the metric. We compared proportions using χ2 tests.

We calculated performance on metrics by specialty and determined which specialties accounted for the most high-risk prescriptions. We present results in Appendix 4 for interested readers but do not discuss them owing to limited space.

Analyses used SAS 9.4 (SAS Institute, Inc, Cary, NC), Stata 15.1 (Stata Corp, College Station, TX), and 2-sided hypothesis tests with α = .05.

The database included 144 734 094 opioid prescriptions dispensed in 2019; 4 030 834 (2.8%) were for patients aged 0 to 21 years. Of these prescriptions, 3133 (0.08%) were excluded. Of the remaining 4 027 701 prescriptions in the sample, 3 487 263 (86.6%) were for adolescents and young adults and 3 250 443 (80.7%) were for opioid-naive patients. Method of payment was commercial insurance for 2 447 863 (60.8%) prescriptions, followed by Medicaid and/or other public insurance (1 106 206; 27.5%), cash (330 225; 8.2%), and Medicare (143 407; 3.6%). Hydrocodone accounted for 2 120 784 (52.7%) prescriptions, followed by oxycodone (857 641; 21.3%), codeine (556 463; 13.8%), and tramadol (395 829; 9.8%); 51 046 (1.3%) prescriptions were for extended-release and/or long-acting opioids. Median days supplied was 3 days (25th–75th percentile: 3–5). The 4 027 701 prescriptions were for 3 131 759 patients; 449 310 (14.3%) patients had multiple dispensed prescriptions in 2019.

In Table 1, we display prevalence estimates overall and by demographic subgroup. Of all US children and young adults, 3.5% had ≥1 dispensed opioid prescription in 2019. For young children aged 0 to 11 years and adolescents and young adults aged 12 to 21 years, this proportion was 0.9% and 6.3%, respectively. The proportion of children and young adults with ≥1 dispensed opioid prescription in 2019 was highest in the south (4.1%).

TABLE 1

Prevalence of Dispensed Opioid Prescriptions Among US Children and Young Adults Aged 0 to 21 Years in 2019

No. Prescriptions (Percentage of Total)No. Patients in the Database With ≥1 Dispensed Opioid Prescription in 2019US Population Denominator From 2019 ACSaRate of Dispensed Opioid Prescriptions per 100 US Children and Young AdultsProportion Of US Children and Young Adults With ≥1 Dispensed Opioid Prescription in 2019
Overall 4 027 701 (100.0) 3 131 759 90 657 309 4.4 3.5 
Age group, y      
 0–11 540 438 (13.4) 427 241 47 552 304 1.1 0.9 
 12–21 3 487 263 (86.6) 2 704 518 43 105 005 8.1 6.3 
Sex      
 Male 1 818 708 (45.2) 1 430 441 46 439 447 3.9 3.1 
 Female 2 203 232 (54.7) 1 696 980 44 217 862 5.0 3.8 
 Unknown 5761 (0.1) 4338 N/Ab N/Ab N/Ab 
Census region      
 Northeast 452 473 (11.2) 364 360 14 426 616 3.1 2.5 
 Midwest 854 430 (21.0) 663 939 19 050 769 4.5 3.5 
 South 1 906 296 (47.3) 1 446 345 35 350 669 5.4 4.1 
 West 824 502 (20.5) 660 969 21 829 255 3.8 3.0 
No. Prescriptions (Percentage of Total)No. Patients in the Database With ≥1 Dispensed Opioid Prescription in 2019US Population Denominator From 2019 ACSaRate of Dispensed Opioid Prescriptions per 100 US Children and Young AdultsProportion Of US Children and Young Adults With ≥1 Dispensed Opioid Prescription in 2019
Overall 4 027 701 (100.0) 3 131 759 90 657 309 4.4 3.5 
Age group, y      
 0–11 540 438 (13.4) 427 241 47 552 304 1.1 0.9 
 12–21 3 487 263 (86.6) 2 704 518 43 105 005 8.1 6.3 
Sex      
 Male 1 818 708 (45.2) 1 430 441 46 439 447 3.9 3.1 
 Female 2 203 232 (54.7) 1 696 980 44 217 862 5.0 3.8 
 Unknown 5761 (0.1) 4338 N/Ab N/Ab N/Ab 
Census region      
 Northeast 452 473 (11.2) 364 360 14 426 616 3.1 2.5 
 Midwest 854 430 (21.0) 663 939 19 050 769 4.5 3.5 
 South 1 906 296 (47.3) 1 446 345 35 350 669 5.4 4.1 
 West 824 502 (20.5) 660 969 21 829 255 3.8 3.0 

N/A, not applicable; ACS, American Community Survey.

a

See Appendix 2 for details on obtaining population denominators.

b

Population denominators for patients of unknown sex could not be calculated. Prevalence estimates for male and female patients would be slightly higher if patient sex were known for these 5761 prescriptions.

In Tables 23, we display performance on the 6 metrics of high-risk prescribing. Among 3 250 443 prescriptions for opioid-naive patients, 1 359 082 (41.8%) and 124 874 (3.8%) exceeded a 3-day and 7-day supply, respectively (Fig 1). Among 540 438 prescriptions for young children, 45 494 (8.4%) and 41 619 (7.7%) were for codeine and tramadol, respectively. Among 3 487 263 prescriptions for adolescents and young adults, 402 430 (11.5%) had a daily MME of ≥50 and 159 269 (4.6%) had benzodiazepine overlap. Among all 4 027 701 prescriptions, 1 834 776 (45.6%) were classified as high risk by ≥1 metric.

FIGURE 1

Distribution of days supplied among dispensed opioid prescriptions for opioid-naive children and young adults. A total of 3 250 443 opioid prescriptions were dispensed to such patients in 2019. Of these, 1 234 208 (38.0%) had days supplied between 4 and 7 days. Additionally, 2508 had days supplied exceeding 30 days; these prescriptions are not depicted in this graph owing to their small numbers.

FIGURE 1

Distribution of days supplied among dispensed opioid prescriptions for opioid-naive children and young adults. A total of 3 250 443 opioid prescriptions were dispensed to such patients in 2019. Of these, 1 234 208 (38.0%) had days supplied between 4 and 7 days. Additionally, 2508 had days supplied exceeding 30 days; these prescriptions are not depicted in this graph owing to their small numbers.

Close modal
TABLE 2

Performance on 2 Metrics Assessing Days Supplied in Opioid Prescriptions for Opioid-Naive Children and Young Adults

Proportion of Prescriptions for Opioid-Naive Patients With Days Supplied >3Proportion of Prescriptions for Opioid-Naive Patients With Days Supplied >7a
No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)
Overall 3 250 443 1 359 082 (41.8) 3 250 443 124 874 (3.8) 
Age group, y     
 0–11 437 914 234 551 (53.6) 437 914 40 770 (9.3) 
 12–21 2 812 529 1 124 531 (40.0) 2 812 529 84 104 (3.0) 
Sex     
 Male 1 478 677 619 295 (41.9) 1 478 677 60 193 (4.1) 
 Female 1 767 313 737 723 (41.7) 1 767 313 64 127 (3.6) 
 Unknown 4453 2064 (46.4) 4453 554 (12.4) 
Census region     
 Northeast 374 372 121 781 (32.5) 374 372 9648 (2.6) 
 Midwest 687 665 283 918 (41.3) 687 665 23 110 (3.4) 
 South 1 504 480 656 505 (43.6) 1 504 480 64 119 (4.3) 
 West 683 926 296 878 (43.4) 683 926 27 997 (4.1) 
Method of payment     
 Commercial 2 034 441 797 592 (39.2) 2 034 441 66 649 (3.3) 
 Medicaid or other public insurance 912 743 412 178 (45.2) 912 743 26 297 (2.9) 
 Cash 271 669 129 039 (47.5) 271 669 25 834 (9.5) 
 Medicareb 31 590 20 273 (64.2) 31 590 6094 (19.3) 
Proportion of Prescriptions for Opioid-Naive Patients With Days Supplied >3Proportion of Prescriptions for Opioid-Naive Patients With Days Supplied >7a
No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)
Overall 3 250 443 1 359 082 (41.8) 3 250 443 124 874 (3.8) 
Age group, y     
 0–11 437 914 234 551 (53.6) 437 914 40 770 (9.3) 
 12–21 2 812 529 1 124 531 (40.0) 2 812 529 84 104 (3.0) 
Sex     
 Male 1 478 677 619 295 (41.9) 1 478 677 60 193 (4.1) 
 Female 1 767 313 737 723 (41.7) 1 767 313 64 127 (3.6) 
 Unknown 4453 2064 (46.4) 4453 554 (12.4) 
Census region     
 Northeast 374 372 121 781 (32.5) 374 372 9648 (2.6) 
 Midwest 687 665 283 918 (41.3) 687 665 23 110 (3.4) 
 South 1 504 480 656 505 (43.6) 1 504 480 64 119 (4.3) 
 West 683 926 296 878 (43.4) 683 926 27 997 (4.1) 
Method of payment     
 Commercial 2 034 441 797 592 (39.2) 2 034 441 66 649 (3.3) 
 Medicaid or other public insurance 912 743 412 178 (45.2) 912 743 26 297 (2.9) 
 Cash 271 669 129 039 (47.5) 271 669 25 834 (9.5) 
 Medicareb 31 590 20 273 (64.2) 31 590 6094 (19.3) 

Opioid-naive patients were those without any dispensed opioid prescriptions during the 90 days to 1 day before the dispensing date of the index prescription.

a

By definition, all prescriptions for opioid-naive patients with days supplied >7 days were included among prescriptions for opioid-naive patients with days supplied >3 days.

b

Medicare covers children and young adults with end-stage renal disease and some children and young adults with disabilities.

TABLE 3

Performance on 4 Age-Specific Metrics of High-risk Prescribing

Proportion of Prescriptions to Young Children for CodeineProportion of Prescriptions to Young Children for TramadolProportion of Prescriptions to AYAs With Daily MME ≥50Proportion of Prescriptions to AYAs With Benzodiazepine Overlap
No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)
Age group, y         
 0–11 540 438 45 494 (8.4) 540 438 41 619 (7.7) N/A N/A N/A N/A 
 12–21 N/A N/A N/A N/A 3 487 263 402 430 (11.5) 3 487 263 159 269 (4.6) 
Sex         
 Male 298 003 24 340 (8.2) 298 003 21 146 (7.1) 1 520 705 187 403 (12.3) 1 520 705 65 001 (4.3) 
 Female 241 208 21 031 (8.7) 241 208 19 953 (8.3) 1 962 024 214 469 (10.9) 1 962 024 94 075 (4.8) 
 Unknown 1227 123 (10.0) 1227 520 (42.4) 4534 558 (12.3) 4534 193 (4.3) 
Census region         
 Northeast 44 250 3012 (6.8) 44 250 3744 (8.5) 408 223 48 281 (11.8) 408 223 19 858 (4.9) 
 Midwest 115 571 7477 (6.5) 115 571 8703 (7.5) 729 859 81 814 (11.2) 729 859 27 899 (3.8) 
 South 286 899 28 354 (9.9) 286 899 23 672 (8.3) 1 618 397 184 779 (11.4) 1 618 397 80 367 (5.0) 
 West 93 718 6651 (7.1) 93 718 5500 (5.9) 730 784 87 556 (12.0) 730 784 31 145 (4.3) 
Method of payment         
 Commercial 268 783 22 721 (8.5) 268 783 22 774 (8.5) 2 179 080 267 919 (12.3) 2 179 080 93 839 (4.3) 
 Medicaid or other public insurance 184 193 9252 (5.0) 184 193 2304 (1.3) 922 013 79 380 (8.6) 922 013 30 315 (3.3) 
 Cash 55 311 11 320 (20.5) 55 311 8986 (16.2) 274 914 29 402 (10.7) 274 914 10 504 (3.8) 
 Medicare 32 151 2201 (6.8) 32 151 7555 (23.5) 111 256 25 729 (23.1) 111 256 24 611 (22.1) 
Proportion of Prescriptions to Young Children for CodeineProportion of Prescriptions to Young Children for TramadolProportion of Prescriptions to AYAs With Daily MME ≥50Proportion of Prescriptions to AYAs With Benzodiazepine Overlap
No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)No. Prescriptions Eligible for MetricNo. Prescriptions in Numerator (%)
Age group, y         
 0–11 540 438 45 494 (8.4) 540 438 41 619 (7.7) N/A N/A N/A N/A 
 12–21 N/A N/A N/A N/A 3 487 263 402 430 (11.5) 3 487 263 159 269 (4.6) 
Sex         
 Male 298 003 24 340 (8.2) 298 003 21 146 (7.1) 1 520 705 187 403 (12.3) 1 520 705 65 001 (4.3) 
 Female 241 208 21 031 (8.7) 241 208 19 953 (8.3) 1 962 024 214 469 (10.9) 1 962 024 94 075 (4.8) 
 Unknown 1227 123 (10.0) 1227 520 (42.4) 4534 558 (12.3) 4534 193 (4.3) 
Census region         
 Northeast 44 250 3012 (6.8) 44 250 3744 (8.5) 408 223 48 281 (11.8) 408 223 19 858 (4.9) 
 Midwest 115 571 7477 (6.5) 115 571 8703 (7.5) 729 859 81 814 (11.2) 729 859 27 899 (3.8) 
 South 286 899 28 354 (9.9) 286 899 23 672 (8.3) 1 618 397 184 779 (11.4) 1 618 397 80 367 (5.0) 
 West 93 718 6651 (7.1) 93 718 5500 (5.9) 730 784 87 556 (12.0) 730 784 31 145 (4.3) 
Method of payment         
 Commercial 268 783 22 721 (8.5) 268 783 22 774 (8.5) 2 179 080 267 919 (12.3) 2 179 080 93 839 (4.3) 
 Medicaid or other public insurance 184 193 9252 (5.0) 184 193 2304 (1.3) 922 013 79 380 (8.6) 922 013 30 315 (3.3) 
 Cash 55 311 11 320 (20.5) 55 311 8986 (16.2) 274 914 29 402 (10.7) 274 914 10 504 (3.8) 
 Medicare 32 151 2201 (6.8) 32 151 7555 (23.5) 111 256 25 729 (23.1) 111 256 24 611 (22.1) 

Young children were those aged 0 to 11 years; AYAs were those aged 12 to 21 years. AYA, adolescent and young adult; N/A, not applicable.

For each metric, the AMEs of demographic characteristics on performance are displayed in Appendix 5. Prescriptions for opioid-naive patients were less likely to exceed a 3-day supply if they were for adolescents and young adults rather than young children (unadjusted difference: −13.6 percentage points; AME: −12.2; 95% confidence interval [CI]: −12.4 to −12.1). The same pattern occurred for prescriptions exceeding a 7-day supply. Prescriptions to young children were less likely to be for codeine if the method of payment was Medicaid and/or other public insurance rather than commercial insurance (unadjusted difference: −3.4 percentage points; AME: −3.6; 95% CI: −3.7 to −3.4). The same pattern occurred for tramadol. For metrics assessing prescriptions to adolescents and young adults with a daily MME of ≥50 and opioid-benzodiazepine overlap, performance differences between demographic subgroups were generally modest.

Of 4 027 701 prescriptions in the sample, 84 470 (2.1%) were excluded in prescriber analyses owing to missing prescriber identifiers. Of the remaining 3 943 231 prescriptions, dentists accounted for 1 504 370 (38.2%) and surgeons accounted for 918 154 (23.3%). These prescribers collectively accounted for 2 422 524 prescriptions (61.4%) (Table 4). Surgical subspecialties accounting for the most prescriptions were orthopedics (7.6% of the 3 943 231 prescriptions) and otolaryngology (6.3%) (Appendix 6). Surgeons (47.1%) accounted for a higher proportion of prescriptions for young children than dentists (11.8%). In contrast, dentists (42.1%) accounted for a higher proportion of prescriptions for adolescents and young adults than surgeons (19.7%) (Appendix 7). General pediatricians accounted for 1.7% of the 3 943 231 prescriptions.

TABLE 4

Opioid Prescriptions Dispensed to Children and Young Adults In 2019, by Prescriber Specialty

SpecialtyNo. PrescriptionsPercentage of All Prescriptions
Dentista 1 504 370 38.2 
Surgeryb 918 154 23.3 
Physician assistant 282 194 7.2 
Emergency medicinec 279 478 7.1 
Nurse practitioner 218 143 5.5 
Family medicined 194 316 4.9 
Obstetrics and/or gynecologye 138 889 3.5 
Internal medicinef 85 539 2.2 
General pediatrics 66 376 1.7 
Podiatry 59 830 1.5 
Pain medicine and anesthesiologyg 43 359 1.1 
Hematology and/or oncologyh 37 655 1.0 
Physical medicine and rehabilitationi 21 059 0.5 
Hospice and/or palliative care 2599 0.1 
All other prescribersj 81 434 2.1 
Unknown 9836 0.2 
Totalk 3 943 231 100.0l 
SpecialtyNo. PrescriptionsPercentage of All Prescriptions
Dentista 1 504 370 38.2 
Surgeryb 918 154 23.3 
Physician assistant 282 194 7.2 
Emergency medicinec 279 478 7.1 
Nurse practitioner 218 143 5.5 
Family medicined 194 316 4.9 
Obstetrics and/or gynecologye 138 889 3.5 
Internal medicinef 85 539 2.2 
General pediatrics 66 376 1.7 
Podiatry 59 830 1.5 
Pain medicine and anesthesiologyg 43 359 1.1 
Hematology and/or oncologyh 37 655 1.0 
Physical medicine and rehabilitationi 21 059 0.5 
Hospice and/or palliative care 2599 0.1 
All other prescribersj 81 434 2.1 
Unknown 9836 0.2 
Totalk 3 943 231 100.0l 
a

Includes general dentists, dental subspecialists (anesthesiology, endodontics, orthodontics, pedodontists, periodontics, and orthodontics), and oral and maxillofacial surgeons.

b

Includes cardiothoracic, colorectal, general, hand, neurosurgery, ophthalmology, orthopedic surgery, otolaryngology, pediatric, plastic, thoracic, transplant, urology, and vascular surgery.

c

Includes pediatric emergency medicine physicians and emergency medicine physicians in clinical informatics, medical toxicology, sports medicine, and underseas medicine.

d

Includes family medicine physicians in clinical informatics, geriatric medicine, and sports medicine and those dually boarded in family medicine and/or psychiatry.

e

Includes general obstetrics and/or gynecology, gynecologic oncology, maternal and fetal medicine, reproductive endocrinology and infertility, and female pelvic medicine and/or reconstructive surgery.

f

Includes internists in sports medicine and geriatrics and physicians dually boarded in internal medicine and anesthesiology, family medicine, pediatrics, and preventive medicine.

g

Includes nonpain medicine anesthesiology and pain medicine physicians from anesthesiology, neurology, physical medicine and/or rehabilitation, and psychiatry.

h

Includes pediatric and nonpediatric hematology and/or oncology.

i

Includes pediatric and nonpediatric physical medicine and rehabilitation. Physical medicine and rehabilitation physicians in pain medicine were classified as pain medicine physicians.

j

Addiction, aerospace, allergy and/or immunology, anesthesiology, cardiology, chiropractic, critical care, dermatology, endocrinology, gastroenterology, general practice, genetics, gastroenterology and/or hepatology, hospitalists, hygienist, infectious disease, legal medicine, microbiology, midwife, military, naturopath, neonatology, nephrology, neurology, neuromuscular medicine, nuclear medicine, nurse, nurse anesthetist, occupational medicine, optometrist, osteopathy, pathology, pharmaceutical medicine, pharmacist, preventive medicine, psychiatry, pulmonology, radiation oncology, radiology, rheumatology, sleep medicine, and toxicology. Also includes pediatricians in the following specialties: adolescent medicine, child abuse, clinical informatics, developmental and/or behavioral, neurodevelopmental, medical toxicology, sports medicine. These pediatricians accounted for just 673 pediatric opioid prescriptions.

k

Sample for this analysis includes 3 943 231 prescriptions with nonmissing prescriber identifiers.

l

Values in the rows above do not add to 100% owing to rounding error.

The 3 943 231 prescriptions were written by 404 102 prescribers. The median prescriber accounted for 3 prescriptions (25th–75th percentile: 1–7). The 95th percentile was 31. Among 20 848 (5.2%) high-volume prescribers with prescription counts of ≥31, 7431 (35.6%) and 6684 (32.1%) were dentists and surgeons; 10 579 (50.7%) practiced in the south. Of the other 383 254 prescribers, 56 371 (14.7%) and 64 997 (17.0%) were dentists and surgeons; 154 852 (40.4%) practiced in the south. High-volume prescribers accounted for 2 100 283 prescriptions (53.3% of 3 943 231 prescriptions) and 950 137 high-risk prescriptions (53.1% of 1 787 721 high-risk prescriptions). Other prescribers accounted for 46.7% and 46.9% of prescriptions and high-risk prescriptions (Figure 2). In Appendix 8, we report results when defining high-volume prescribers as those with prescription counts at the ≥99th percentile.

For each metric, we display the proportion of eligible prescriptions from high-volume prescribers and other prescribers that were classified as high-risk in Figure 3. This proportion was consistently higher among prescriptions from other prescribers (median difference: 2.9 percentage points; P < .001 for all differences).

FIGURE 2

Percent of pediatric opioid prescriptions and high-risk prescriptions accounted for by high-volume prescribers and other prescribers in 2019. High-volume prescribers were the 20 848 prescribers with prescription counts at the 95th percentile or above among all clinicians who accounted for ≥1 dispensed opioid prescription to children and young adults in 2019. Other prescribers were the 383 254 prescribers with prescriptions below the 95th percentile. Data source: 2019 IQVIA Longitudinal Prescription Database.

FIGURE 2

Percent of pediatric opioid prescriptions and high-risk prescriptions accounted for by high-volume prescribers and other prescribers in 2019. High-volume prescribers were the 20 848 prescribers with prescription counts at the 95th percentile or above among all clinicians who accounted for ≥1 dispensed opioid prescription to children and young adults in 2019. Other prescribers were the 383 254 prescribers with prescriptions below the 95th percentile. Data source: 2019 IQVIA Longitudinal Prescription Database.

Close modal
FIGURE 3

Percent of eligible opioid prescriptions from high-volume prescribers and other prescribers that were classified as high-risk by 6 metrics. High-volume prescribers were the 20 848 prescribers with prescription counts at the 95th percentile or above among all clinicians who accounted for ≥1 dispensed opioid prescription to children and young adults in 2019. Other prescribers were the 383 254 prescribers with prescriptions below the 95th percentile. Data source: 2019 IQVIA Longitudinal Prescription Database. AYA, adolescent and young adult; MME, morphine milligram equivalents.

FIGURE 3

Percent of eligible opioid prescriptions from high-volume prescribers and other prescribers that were classified as high-risk by 6 metrics. High-volume prescribers were the 20 848 prescribers with prescription counts at the 95th percentile or above among all clinicians who accounted for ≥1 dispensed opioid prescription to children and young adults in 2019. Other prescribers were the 383 254 prescribers with prescriptions below the 95th percentile. Data source: 2019 IQVIA Longitudinal Prescription Database. AYA, adolescent and young adult; MME, morphine milligram equivalents.

Close modal

In 2019, almost half of the 4 million opioid prescriptions dispensed to US children and young adults were classified as high risk by at least 1 of 6 metrics. Dentists and surgeons collectively accounted for 6 in 10 prescriptions. Approximately 20 000 high-volume prescribers (those with prescription counts at the ≥95th percentile) accounted for 53% of all prescriptions and high-risk prescriptions.

In this study, we provide national data on the prevalence and demographic correlates of high-risk pediatric opioid prescribing. In 2019, 41.8% and 3.8% of opioid prescriptions dispensed to opioid-naive children and young adults exceeded a 3-day and 7-day supply, respectively, although many of these prescriptions likely were for dental and surgical procedures that do not require long durations of opioid therapy.11,19,20,27  Investigators have substantially reduced opioid quantities in perioperative prescriptions for adult patients by developing procedure-specific prescribing guidelines on the basis of data on patient-reported postoperative opioid consumption.28,29  Similar efforts have begun in some pediatric institutions30  but should be more widespread. Our findings highlight the importance of including young children in such efforts. In 2019, prescriptions for opioid-naive patients were more likely to exceed a 3-day supply if they were for young children rather than for adolescents and young adults, potentially because the latter were more likely to receive dental opioid prescriptions, which are typically of short duration.31 

Approximately 1 in 6 opioid prescriptions dispensed to young children were for codeine or tramadol, both contraindicated in this age group.22  The persistent use of codeine is consistent with a study revealing incomplete reductions in codeine prescribing to children undergoing tonsillectomy after a 2013 Food and Drug Administration contraindication.32,33  To reduce codeine and tramadol prescribing to young children, electronic health record systems and pharmacists could prompt clinicians to consider alternatives when this prescribing is attempted. Additionally, insurers could refuse to cover codeine or tramadol prescriptions for young children.

Among opioid prescriptions dispensed to adolescents and young adults, 11.5% had daily opioid dosages of ≥50 MMEs. In the rare instances in which such elevated dosages are required for children and young adults (eg, cancer pain), interventions to mitigate overdose risk should be considered, such as coprescribing naloxone.34  Moreover, 4.6% of opioid prescriptions dispensed to adolescents and young adults overlapped with a benzodiazepine prescription. In this population, benzodiazepines have limited evidence of efficacy for anxiety, the most common indication for these medications.35  Reducing low-value benzodiazepine prescribing may therefore be a feasible method to reduce concurrent opioid and benzodiazepine exposure.

The outsized role of dentists and surgeons in pediatric opioid prescribing suggests that reductions in prescribing by these clinicians could substantially lower prescription opioid exposure in children and young adults. Evidence suggests such reductions could be achieved without compromising pain control. For example, almost 80% of dental opioid prescriptions for adolescents and young adults are for tooth extraction,31  a procedure for which ibuprofen provides effective analgesia.36  As another example, randomized trials suggest opioids and ibuprofen provide equivalent analgesia for tonsillectomy, a common pediatric surgery.37,38  Despite this, researchers reported that 6 in 10 privately insured children undergoing tonsillectomy from 2016 to 2017 had dispensed perioperative opioid prescriptions.39  Avoiding opioid prescribing for surgical and dental procedures not only decreases the risk of misuse and overdose but also decreases the risk of side effects, such as vomiting and constipation.40  Consequently, when nonopioids provide effective analgesia, first-line use of these medications could improve safety and patient experience.

Approximately 20 000 high-volume prescribers accounted for 53% of pediatric opioid prescriptions. The concentrated nature of pediatric opioid prescribing is consistent with a previous study of opioid prescribing to privately insured Americans, most of whom were adults.41  Notably, high-volume prescribers may not necessarily have high rates of opioid prescribing. For example, surgeons whose patient volume is higher than average may be high-volume prescribers even if their prescribing rates are similar to other surgeons. Nonetheless, the outsized role of high-volume prescribers in pediatric opioid prescribing suggests that their prescribing rates may warrant particular attention.

High-volume prescribers also accounted for 53% of high-risk prescriptions. This finding suggests that initiatives to improve the safety of pediatric opioid prescribing may be most efficient if they target high-volume prescribers. Importantly, however, other prescribers collectively accounted for 47% of high-risk prescriptions and had slightly worse performance on metrics of high-risk prescribing compared with high-volume prescribers. Consequently, broad-based initiatives inclusive of all prescribers should also be considered.

We estimate that 6.3% of US adolescents and young adults had dispensed opioid prescriptions in 2019. This estimate is markedly lower than the prevalence of past-year opioid use reported by adolescents and young adults participating in the National Survey on Drug Use and Health (NSDUH). In the 2015–2016 NSDUH, 17.2% and 24.4% of respondents aged 12 to 17 years and 18 to 25 years, respectively, reported past-year use of opioids prescribed to them but no past-year misuse of their opioids or of opioids prescribed to others.42  A caveat is that US opioid prescribing has declined since 2015, partly owing to heightened awareness of the opioid epidemic.43  Moreover, past-year opioid use could include use of leftover opioids from prescriptions written more than a year ago. Additional research is needed to reconcile our estimates with the NSDUH.

Study strengths include our use of timely national data. However, limitations exist. First, analyses underestimate the prevalence of dispensed opioid prescriptions among US children and young adults because data do not include all pharmacies. Second, dispensing from hospital-specific pharmacies was not observed. Some hospitals with such pharmacies may be affiliated with academic medical centers, which may have prescribing practices that differ from other settings. Third, the role of surgical care in pediatric opioid prescribing is underestimated in our analyses because physician assistants and nurse practitioners account for one-fifth of perioperative opioid prescriptions.44  Fourth, because data lacked clinical details, the denominator for estimates of the prevalence of dispensed opioid prescriptions could not be restricted to patients with potential indications for opioids (eg, injuries). Finally, the outbreak of coronavirus disease 2019 delayed many dental and surgical procedures,4547  the primary indications for pediatric opioid prescribing. Consequently, the rate of this prescribing during the pandemic is likely lower than in 2019. However, findings will still inform quality improvement initiatives, unless the pandemic permanently alters practice.

Reducing opioid prescribing by dentists and surgeons could substantially lower prescription opioid exposure in children and young adults. To improve the safety of pediatric opioid prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.

Dr Chua conceptualized and designed the study, collected the data, analyzed and interpreted the data, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Brummett and Conti conceptualized and designed the study, analyzed and interpreted the data, and reviewed and revised the manuscript; Dr Bohnert conceptualized and designed the study, analyzed and interpreted the data, reviewed and revised the manuscript, and provided study supervision; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by the Susan B. Meister Child Health Evaluation and Research Center and the Janette Ferrantino Award (University of Michigan). Further support was provided by the Substance Abuse and Mental Health Services Administration and the University of Michigan Precision Health Initiative. Dr Chua is supported by a career development award from the National Institute on Drug Abuse (1K08DA048110). The funding sources played no role in the design of the study; the collection, analysis, and interpretation of the data; and the decision to approve publication of the finished article. Funded by the National Institutes of Health (NIH).

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-052190.

     
  • AME

    average marginal effect

  •  
  • CI

    confidence interval

  •  
  • MME

    morphine milligram equivalent

  •  
  • NSDUH

    National Survey on Drug Use and Health

1
Chung
CP
,
Callahan
ST
,
Cooper
WO
, et al
.
Outpatient opioid prescriptions for children and opioid-related adverse events
.
Pediatrics
.
2018
;
142
(
2
):
e20172156
2
Groenewald
CB
,
Zhou
C
,
Palermo
TM
,
Van Cleve
WC
.
Associations between opioid prescribing patterns and overdose among privately insured adolescents
.
Pediatrics
.
2019
;
144
(
5
):
e20184070
3
Chua
KP
,
Brummett
CM
,
Conti
RM
,
Bohnert
A
.
Association of opioid prescribing patterns with prescription opioid overdose in adolescents and young adults
.
JAMA Pediatr
.
2020
;
174
(
2
):
141
148
4
Harbaugh
CM
,
Lee
JS
,
Hu
HM
, et al
.
Persistent opioid use among pediatric patients after surgery
.
Pediatrics
.
2018
;
141
(
1
):
e20172439
5
Gaither
JR
,
Leventhal
JM
,
Ryan
SA
,
Camenga
DR
.
National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012
.
JAMA Pediatr
.
2016
;
170
(
12
):
1195
1201
6
Gaither
JR
,
Shabanova
V
,
Leventhal
JM
.
US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016
.
JAMA Netw Open
.
2018
;
1
(
8
):
e186558
7
Miech
R
,
Johnston
L
,
O’Malley
PM
,
Keyes
KM
,
Heard
K
.
Prescription opioids in adolescence and future opioid misuse
.
Pediatrics
.
2015
;
136
(
5
):
e1169
e1177
8
McCabe
SE
,
Boyd
CJ
,
Evans-Polce
RJ
,
McCabe
VV
,
Schulenberg
JE
,
Veliz
PT
.
Pills to powder: a 17-year transition from prescription opioids to heroin among US adolescents followed into adulthood
.
J Addict Med
.
2020
;
15
(
3
):
241
244
9
Quinn
PD
,
Fine
KL
,
Rickert
ME
, et al
.
Association of opioid prescription initiation during adolescence and young adulthood with subsequent substance-related morbidity
.
JAMA Pediatr
.
2020
;
174
(
11
):
1048
1055
10
McCabe
SE
,
West
BT
,
Boyd
CJ
.
Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study
.
J Adolesc Health
.
2013
;
52
(
4
):
480
485
11
Voepel-Lewis
T
,
Wagner
D
,
Tait
AR
.
Leftover prescription opioids after minor procedures: an unwitting source for accidental overdose in children
.
JAMA Pediatr
.
2015
;
169
(
5
):
497
498
12
Chua
KP
,
Brummett
CM
,
Conti
RM
,
Haffajee
RL
,
Prosser
LA
,
Bohnert
ASB
.
Assessment of prescriber and pharmacy shopping among the family members of patients prescribed opioids
.
JAMA Netw Open
.
2019
;
2
(
5
):
e193673
13
Gagne
JJ
,
He
M
,
Bateman
BT
.
Trends in opioid prescription in children and adolescents in a commercially insured population in the United States, 2004-2017
.
JAMA Pediatr
.
2019
;
173
(
1
):
98
99
14
Brown
KW
,
Carlisle
K
,
Raman
SR
, et al
.
Children and the opioid epidemic: age-stratified exposures and harms
.
Health Aff (Millwood)
.
2020
;
39
(
10
):
1737
1742
15
Basco
WT
 Jr
,
McCauley
JL
,
Zhang
J
, et al
.
Trends in dispensed opioid analgesic prescriptions to children in South Carolina: 2010-2017
.
Pediatrics
.
2021
;
147
(
3
):
e20200649
16
Hardin
AP
,
Hackell
JM
;
COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE
.
Age limit of pediatrics
.
Pediatrics
.
2017
;
140
(
3
):
e20172151
17
United States Census Bureau
.
American Community Survey (ACS)
.
2021
.
Available at: https://www.census.gov/programs-surveys/acs. Accessed January 2, 2021
18
Dowell
D
,
Haegerich
TM
,
Chou
R
.
CDC guideline for prescribing opioids for chronic pain - United States, 2016
.
MMWR Recomm Rep
.
2016
;
65
(
1
):
1
49
19
Monitto
CL
,
Hsu
A
,
Gao
S
, et al
.
Opioid prescribing for the treatment of acute pain in children on hospital discharge
.
Anesth Analg
.
2017
;
125
(
6
):
2113
2122
20
Harbaugh
CM
,
Vargas
G
,
Streur
CS
, et al
.
Eliminating unnecessary opioid exposure after common children’s surgeries
.
JAMA Surg
.
2019
;
154
(
12
):
1154
1155
21
Pharmacy Quality Alliance
.
PQA measures overview
.
2020
.
22
Food and Drug Administration
.
FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women
.
2017
.
Available at: https://www.fda.gov/downloads/Drugs/DrugSafety/UCM553814.pdf. Accessed January 2, 2021
23
Centers for Disease Control and Prevention
.
Data resources: analyzing prescription data and morphine milligram equivalents (MME)
.
2020
.
Available at: https://www.cdc.gov/drugoverdose/resources/data.html. Accessed January 2, 2021
24
Basco
WT
 Jr
,
Ebeling
M
,
Garner
SS
,
Hulsey
TC
,
Simpson
K
.
Opioid Prescribing and Potential Overdose Errors Among Children 0 to 36 Months Old
.
Clin Pediatr (Phila)
.
2015
;
54
(
8
):
738
744
25
Centers for Disease Control and Prevention
.
Weight-for-age charts, 2 to 20 years, selected weight z-scores in kilograms, by sex and age
.
2009
.
Available at: https://www.cdc.gov/growthcharts/data/zscore/zwtage.xls. Accessed January 2, 2021
26
Norton
EC
,
Dowd
BE
,
Maciejewski
ML
.
Marginal effects-quantifying the effect of changes in risk factors in logistic regression models
.
JAMA
.
2019
;
321
(
13
):
1304
1305
27
Nalliah
RP
,
Sloss
KR
,
Kenney
BC
, et al
.
Association of opioid use with pain and satisfaction after dental extraction
.
JAMA Netw Open
.
2020
;
3
(
3
):
e200901
28
Vu
JV
,
Howard
RA
,
Gunaseelan
V
,
Brummett
CM
,
Waljee
JF
,
Englesbe
MJ
.
Statewide implementation of postoperative opioid prescribing guidelines
.
N Engl J Med
.
2019
;
381
(
7
):
680
682
29
Michigan Opioid Prescribing Engagement Network
.
Opioid prescribing recommendations
.
2020
.
Available at: https://opioidprescribing.info. Accessed January 2, 2021
30
Freedman-Weiss
MR
,
Chiu
AS
,
Worhunsky
D
, et al
.
An evidence-based guideline supporting restricted opioid prescription after pediatric appendectomy
.
J Pediatr Surg
.
2020
;
55
(
1
):
106
111
31
Chua
KP
,
Hu
HM
,
Waljee
JF
,
Brummett
CM
,
Nalliah
RP
.
Opioid prescribing patterns by dental procedure among US publicly and privately insured patients, 2013 through 2018
.
J Am Dent Assoc
.
2021
;
152
(
4
):
309
317
32
Chua
KP
,
Shrime
MG
,
Conti
RM
.
Effect of FDA investigation on opioid prescribing to children after tonsillectomy/adenoidectomy
.
Pediatrics
.
2017
;
140
(
6
):
e20171765
33
Food and Drug Administration
.
Safety review update of codeine use in children; new Boxed Warning and Contraindication on use after tonsillectomy and/or adenoidectomy
.
2013
.
Available at: https://www.fda.gov/media/85072/download. Accessed January 2, 2021
34
Guy
GP
 Jr
,
Strahan
AE
,
Haegerich
T
, et al
.
Concurrent naloxone dispensing among individuals with high-risk opioid prescriptions, USA, 2015-2019 [published online ahead of print March 9, 2021]
.
J Gen Intern Med
.
doi:10.1007/s11606-021-06662-3
35
Wang
Z
,
Whiteside
SPH
,
Sim
L
, et al
.
Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis
.
JAMA Pediatr
.
2017
;
171
(
11
):
1049
1056
36
Moore
PA
,
Ziegler
KM
,
Lipman
RD
,
Aminoshariae
A
,
Carrasco-Labra
A
,
Mariotti
A
.
Benefits and harms associated with analgesic medications used in the management of acute dental pain: an overview of systematic reviews
.
J Am Dent Assoc
.
2018
;
149
(
4
):
256
265.e3
37
Kelly
LE
,
Sommer
DD
,
Ramakrishna
J
, et al
.
Morphine or ibuprofen for post-tonsillectomy analgesia: a randomized trial
.
Pediatrics
.
2015
;
135
(
2
):
307
313
38
St Charles
CS
,
Matt
BH
,
Hamilton
MM
,
Katz
BP
.
A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient
.
Otolaryngol Head Neck Surg
.
1997
;
117
(
1
):
76
82
39
Chua
KP
,
Harbaugh
CM
,
Brummett
CM
, et al
.
Association of perioperative opioid prescriptions with risk of complications after tonsillectomy in children
.
JAMA Otolaryngol Head Neck Surg
.
2019
;
145
(
10
):
911
918
40
Kelley-Quon
LI
,
Kirkpatrick
MG
,
Ricca
RL
, et al
.
Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion
.
JAMA Surg
.
2021
;
156
(
1
):
76
90
41
Kiang
MV
,
Humphreys
K
,
Cullen
MR
,
Basu
S
.
Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study
.
BMJ
.
2020
;
368
:
l6968
42
McCabe
SE
,
Wilens
TE
,
Boyd
CJ
,
Chua
KP
,
Voepel-Lewis
T
,
Schepis
TS
.
Age-specific risk of substance use disorders associated with controlled medication use and misuse subtypes in the United States
.
Addict Behav
.
2019
;
90
:
285
293
43
Centers for Disease Control and Prevention
.
U.S. opioid dispensing rate maps
.
2020
.
Available at: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html. Accessed December 30, 2020
44
Cron
DC
,
Lee
JS
,
Dupree
JM
, et al
.
Provider characteristics associated with outpatient opioid prescribing after surgery
.
Ann Surg
.
2020
;
271
(
4
):
680
685
45
FAIR Health
.
Dental services and the impact of covid-19: an analysis of private claims
.
2020
.
46
Wolfson
B
.
The pandemic is hurting pediatric hospitals, too
.
Kaiser Health News
.
2020
.
47
Meredith
JW
,
High
KP
,
Freischlag
JA
.
Preserving elective surgeries in the COVID-19 pandemic and the future
.
JAMA
.
2020
;
324
(
17
):
1725
1726

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Brummett serves as a paid consultant for Heron Therapeutics, Vertex Pharmaceuticals, and Alosa Health and has received fees for expert testimony. The other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data