Melanie Cole, MS (Host): The ongoing opioid epidemic, typically, as we’ve heard about it refers to adults, but children and adolescents undergoing surgery are at risk too of dependents and addiction to opioid medications. My guest is Dr. Ellen Raney. She’s a pediatric orthopedic surgeon at Shriners Hospital for Children in Portland. Dr. Raney I’m so glad to have you on today to talk about this really important topic. Tell us, if you can, how the opioid epidemic is affecting the pediatric population?

Ellen Raney, M.D. (Guest): Hi yes, thanks for having me. This is a very interesting topic, and I think we just didn’t realize before how pervasive it’s become. Now we know that nearly one in four high school seniors has had exposure to prescription opioids. Most of those adolescents start out with a prescription from a doctor for a painful event, like from a surgery or for an injury, and that’s called medical use. Now we understand that even adolescents who start out with this prescription are high risk of later using opioids for something else, such as say anxiety or recreation and that kind of use is called nonmedical use of opioids. Even five percent of middle schoolers down in the seventh and eighth grade report this nonmedical use of opioids. Then tragically even young children and toddlers have been exposed accidentally by taking medications that they found lying around the house.

Host: How scary is that? So, you were involved in an article for the Journal of Pediatric Orthopedics on the current state of the opioid epidemic as it pertains to the pediatric population and pediatric orthopedics specifically. Can you summarize some of your findings for us?

Dr. Raney: Sure. We found a huge variation among our colleges in pediatric orthopedics in what type of medications and more importantly how long these medications are prescribed after surgeries or after broken bones or injuries. This went all the way from as low as a couple of days’ worth to some of our colleagues that were giving medications for more than a month for something as small as a knee arthroscopy.

Host: Wow, so what was the most concerning or shocking finding that you discovered?

Dr. Raney: Well, when I began this research what I was really surprised to discover is that what we would consider to be good doctors, doctors who are just trying to make sure that their patients don’t have pain after an injury or after a surgery, that we are, actually, the bulk of the problem in the United States. Patients are taking a little as a third of the amount of narcotics that we’re using to prescribe after surgery. Previously, at least I personally always just thought this epidemic was stemming from doctors who are running so called pill mills and just giving pills out for cash or drugs that were made and sold illegally.

Host: Wow, really it is a very concerning situation both for children and adults, but more importantly for children. So what practices, Dr. Raney, can prescribing physicians follow too make sure that they’re not contributing to the opioid crisis? What do you recommend that they do, and when do you feel it’s important that they recommend to a pain specialist?

Dr. Raney: Sure. Well, starting at the beginning when we meet people and when we’re starting planning a surgery, we think its most important that we talk about families--You know if you have the advantage of something in advance, right. I can’t talk to you before you wrecked your car because I’d tell you not to wreck your car. But if we have the opportunity to talk to somebody in advance, then we can talk to them about how they’re going to manage the pain and what their expectations are; maybe what their previous exposures are to opioids and how they coped with pain in the past.

We have twelve surgeons specializing in children’s orthopedics at Shriners Hospital. We’re really concentrating on how many narcotics we’ve prescribed in the past, and what the absolute number is that we feel people need to have to be reasonable control after surgery, and then more importantly what we can do afterwards. Some of the stuff we can work on before surgery is, again, not only expectations, but what are other things people can do like positive imagery or mental things to help you get through surgeries better. There’s also ice, elevation, and they don’t have the be narcotics. Many of these things can be treated with anti-inflammatories.

We also at Shriners Hospital in Portland have five children’s anesthesiologists who are really helping us to keep children more comfortable after surgeries or after injuries such as things like regional anesthesia. Which means injecting a medication around the spin such as an epidural or injecting medication around a nerve, which is called a nerve block. Then after surgery you don’t start out in as much pain and then it seems to set you off on a better course afterwards.

Host: What a great explanation Dr. Raney. You really are a very good educator and explaining this so well because it’s quite a comprehensive and complicated topic, really. So, what do you want parents to do that can help cut down on opioid use for their children? Because as a parent myself if a doctor was going to prescribe it, I would wonder “is this going to be a problem?” So, what do you want parents to do?

Dr. Raney: Sure. Well, the first and most obvious solution is that if you have any extra medication lying around your house from something that you might personally or some other adult in the house might have had previously is to get rid of it. That’s the most obvious solution is to not have any extra. There’s environmentally safe ways to dispose of medication. There’s places that will take them back. Then in a larger scale, as we said, talking to families to manage expectations. We’re finding that parents can be our best allies whereas before there was this thinking of “I want a lot of drugs; I want my child to be very comfortable.” Now we can talk to families and say, “well the last thing in the world that you want is your child to become addicted.” So, we understand that we want to limit the number of opioids or narcotics that the children get, and then all the families say, “oh of course, we want to avoid that.” Then as a larger thought, you know, as a society and as parents, we really need to work on teaching resiliency and teaching people that it’s okay to have an ache or a pain now and then. We need to learn to live with things and life isn’t easy, and we need to just not always reach for a pill every time we have discomfort or anxiety.

Host: That’s great advice. It really is. So, what current steps are the medical team at Shriners Hospital for Children in Portland taking to help cut down on the affects of the opioid crisis for their patients? Give us your best advice. Wrap it up for us, what do you want the take home message to be?

Dr. Raney: Sure. Well, what we’re doing specifically at Shriners is we’re really getting a handle on exactly what we prescribe. And we’re really making a uniform effort to talk to families before we start the surgery, before we get there, before it’s a problem so that we understand what we’re doing, and we understand why we’re doing it so that we can cut down on any excess we’re accidentally giving. And then, again, working with people to look for other ways to deal with discomfort and not for reaching for a bottle every time they have a problem. I think the biggest thing here is we’ve got whole teams of doctors, the surgeons, and the anesthesiologists working together and working with the nurses and working with families before surgery so that we can make a better plan after surgery.

Host: That’s so important. Thank you Dr. Raney for coming on and discussing this really, really important topic for parents so that they can hear from the experts, such as yourself, on other methods that they can try and questions that they can ask. Thank you again for joining us. For more information, please visit portlandshrinershospital.org. That’s portlandshrinershospital.org. This is Melanie Cole. Thanks so much for tuning in.