ORIGINAL ARTICLE
Opioid Prescribing Practices in Pediatric
Acute Care Settings
Michelle DePhillips, MD,* Jennifer Watts, MD, MPH,* Jennifer Lowry, MD,†
and M. Denise Dowd, MD, MPH*
Objectives: Deaths due to prescription opioid overdoses are at record-
high levels. Limiting the amount of opioid prescribed has been suggested
as a prevention strategy. The purpose of this study was to describe the opi-
oid prescribing practices in the emergency departments and urgent care
sites of a Midwestern tertiary care children’s hospital system.
Methods: This retrospective medical record review examined the visits
from the 2 pediatric emergency departments and 2 pediatric urgent care
sites in the system from June 1, 2012, to May 31, 2013, during which an
outpatient opioid prescription was written. The primary outcome was num-
ber of days of opioid prescribed. Other data collected included patient de-
mographics, diagnosis, and prescriber information; factors associated with
prescriptions written for more than 5 days were identified.
Results: A total of 4075 opioid prescriptions were included in the 1-year
study period, and 3991 of these had complete data for analysis. The median
amount prescribed was 3.3 days with an interquartile range of 2.5 days.
Odds of receiving a prescription of more than 5 days’ duration were higher
for children younger than 1 year (odds ratio [OR], 12.3; 95% confidence
interval [CI], 7.3–21.0), 1 to 4 years of age (OR, 7.7; 95% CI, 5.5–10.8),
and 5 to 9 years of age (OR, 2.4; 95% CI, 1.7–3.4); for children with non-
injury diagnoses (OR, 1.4; 95% CI, 1.2–1.7); or if prescribed by a resident
physician (OR, 1.4; 95% CI, 1.1–1.8) or from the urgent care (OR, 1.4;
95% CI, 1.1–1.7).
Conclusions: Opioid prescriptions of more than 5 days were more fre-
quently prescribed for younger patients, noninjury diagnoses, or if pre-
scribed by a resident physician or from the urgent care. We need to focus
on medical student, resident, and provider education as well as further opi-
oid research in order to decrease unnecessary prescribing.
Key Words: opioids, overdose, prescribing practices
(Pediatr Emer Care 2017;00: 00–00)
T he trend in overdose deaths from prescription drugs in the
United States was declared an epidemic by the Centers of Dis-
ease Control and Prevention (CDC) in 2011.1 In 2013, there were
43,982 deaths due to drug overdose, and 37% were due to opioids,
making it more common than overdose from cocaine and heroin
combined.2,3 The rate of poisoning deaths from prescription opi-
oid analgesics nearly quadrupled from 1.4 per 100,000 in 1999
to 5.4 per 100,000 in 2011.4 Concomitantly, there has been a rise
in the prescribing of opioid painkillers, with a 4-fold increase in
sales from 1999 to 2010. This trend is thought to be related to
the standards for consistent monitoring and pain treatment intro-
duced by the Joint Commission on Accreditation of Healthcare
Organizations in 2000 to combat inadequate treatment of pain.3,5
From the Departments of *Emergency Medicine and †Pharmacology, Toxicol-
ogy, and Therapeutic Innovations, Children’s Mercy Hospital, Kansas
City, MO.
Reprints: Michelle DePhillips, MD, Department of Emergency Medicine,
Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108
(e‐mail: mdephillips@cmh.edu).
Disclosure: The authors declare no conflict of interest.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2017
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Concern for overprescribing of opioids in light of the increase in
overdose deaths was first reported by the CDC in the late 2000s.1
The availability of opioids in home settings increases the risk
of children and teens finding and ingesting the medication, either
intentionally or unintentionally. Between 2001 and 2008, there
was a 101% increase in the percentage of pediatric emergency de-
partment (ED) visits due to opioid ingestion, as well as more than
a 5-fold increase in death rates from opioid overdose in the 15- to
24-year age group.6,7 The number of prescriptions written for chil-
dren for controlled medications including opioids nearly doubled
between 1994 and 2007.8
It is estimated that 39% of all opioid prescriptions originate
in an ED.9 Between 2001 and 2010, the proportion of adult ED
visits where an opioid analgesic was prescribed increased from
21% to 31%.10 There is a large variability in opioid prescribing
practices among ED physicians including the decision to prescribe
or not prescribe based on diagnosis or patient characteristics and
how many doses are given.11,12
National attention focused on prevention, intervention, and
treatment of opioid abuse has recently increased. The Obama Ad-
ministration and the Office of National Drug Control Policy re-
cently hosted a summit that called for more educational resources
for patients and providers, intervention, and treatment.13 Currently,
more than 30 states have developed task forces to respond to this
crisis, and several states have set forth their own guidelines for opi-
oid prescribing. These guidelines advise that treatment for acute
pain should be limited to only the necessary amount, with some rec-
ommendations suggesting limiting the total prescription amount to
3 days or at most 7 days.14–19
Although there have been studies examining opioid prescrib-
ing practices for adult patients, few have evaluated practices in the
pediatric population.20–23 Our study sought to describe the opioid
prescribing practices in our pediatric ED and urgent care (UC) set-
tings and to identify demographic and clinical factors associated with
the total quantity of opioids prescribed. By identifying these relation-
ships, we may be able to target interventions to improve opioid pre-
scribing practices and subsequently decrease the amount of opioids
available for nonmedical use and abuse in the home and community.
METHODS
Study Design
This retrospective review utilized the hospital discharge data-
base to identify any ED or UC visits during which an outpatient
prescription for an oral opioid narcotic was written. The project
was approved by the hospital system’s institutional review board,
and consent was waived given the deidentified and retrospective
nature of the data collected.
Study Setting and Population
The setting for this study was a large Midwestern tertiary
care pediatric health care system that included 2 children’s
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DePhillips et al Pediatric Emergency Care • Volume 00, Number 00, Month 2017

hospital EDs, 1 urban and 1 suburban, and 2 children’s UC sites,
both suburban. Table 1 shows the number of visits and patient de-
mographics by site. The urban ED is staffed by pediatric emer-
gency medicine (PEM)–trained physicians and fellows and the
pediatric, emergency medicine (EM), and family practice resi-
dents they supervise, as well as a few EM-trained physicians.
The suburban ED is staffed by PEM physicians, general pediatri-
cians, and nurse practitioners. Pediatric emergency medicine phy-
sicians work only in the children’s EDs in our system. The UCs
are staffed by general pediatricians and nurse practitioners. Visits
for all children 18 years or younger who were discharged from the
ED or UC from June 1, 2012, to May 31, 2013, and who received
an outpatient prescription for an oral opioid narcotic were in-
cluded in this study. Visits were identified using the electronic
central discharge database, which captured all visits during the
study period.
sprains, burns, and dental and eye injuries. The most common
noninjury diagnoses included abscesses, ear and throat pain, viral
illness, stomatitis, and abdominal pain. The majority of these co-
variates were chosen based on previous literature, which showed
that opioids were more frequently prescribed for patients who
were female, adolescent, and white and for those with private in-
surance or written from an urban ED.10,24
The primary outcome of interest was the opioid prescription
duration in days. As the majority of prescriptions were written for
a specific dispense quantity and did not include length of treat-
ment, the number of days was calculated. This was achieved by di-
viding the total dose prescribed in milligrams (dispense quantity
in tablets or milliliters  strength of medication) by the total daily
dose (number of doses per day  prescribed dose). The visit was
excluded from the analysis if information needed to make this cal-
culation was missing.

Study Protocol Data Analysis

For each visit, several covariates of interest were obtained in-
cluding patient demographics (sex, age, language, race/ethnicity,
and insurance), as well as the type of opioid, amount prescribed
(in total milligrams), number of refills, patient weight (in kilo-
grams), location (urban or suburban, ED or UC), primary Interna-
tional Classification of Diseases, Ninth Revision diagnosis, and
prescriber type (PEM physician, general pediatrician, or resident).
In the 2 states where the study settings are located, nurse practi-
tioners cannot prescribe narcotics, and resident physicians can.
Diagnoses were further divided into injury and noninjury catego-
ries because it was felt that providers view pain differently in re-
gard to the mechanism and duration in injury and noninjury
diagnoses. The most common injury diagnoses included fractures,
We examined clinical and demographic factors to identify
those associated with a prescription duration of more than 5 days.
Five days was chosen because it is consistent with many of the al-
ready proposed state guidelines.14–19 To examine demographic
and clinical factors associated with prescription duration of more
than 5 days, we first used univariate logistic regression to calculate
odds ratios (ORs) with 95% confidence intervals (CIs) and corre-
sponding P values. Demographic and clinical factors then included
in the multivariate analysis were those found to be significant, as de-
fined by P < 0.05, in the univariate analysis. The reference groups
chosen for the analysis were based off of previous data that showed
that white female adolescents with private insurance and seen in an
urban ED were more likely to receive opioid prescriptions.10,24 We

TABLE 1. Visits and Patient Demographics by Location

Pediatric ED Site 1 Pediatric ED Site 2 Pediatric UC Site 1 Pediatric UC Site 2 Total

Location Urban Suburban Suburban Suburban
Annual visits 69,180 45,055 28,393 15,524 158,152
Sex
Male 52% 54% 51% 51% 52%
Female 48% 46% 49% 49% 48%
Primary language
English 86% 92% 96% 98% 91%
Spanish 12% 7% 2% 1% 8%
Other 2% 1% 2% 1% 1%
Race/ethnicity
White 32% 53% 67% 68% 48%
Black 38% 24% 11% 15% 27%
Hispanic 21% 13% 7% 6% 15%
Other 9% 10% 15% 11% 10%
Payment source
Government 61% 48% 43% 31% 51%
Commercial 19% 41% 43% 63% 34%
Self-pay/other 20% 11% 14% 6% 15%
Age
<1 y 17% 17% 13% 15% 16%
1–4 y 36% 39% 39% 40% 38%
5–9 y 23% 23% 26% 24% 24%
10–14 y 16% 15% 16% 15% 15%
>14 y 8% 6% 6% 6% 7%

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Pediatric Emergency Care • Volume 00, Number 00, Month 2017 Opioid Prescribing Practices

Characteristics Associated With Prescriptions for

More Than 5-Day Supply of Opioids
A univariate analysis revealed several factors associated with
prescriptions for more than 5 days. These included younger pa-
tients, visits taking place in UC areas, prescriptions written by gen-
eral pediatricians, and those with noninjury diagnoses (Table 3). We
found no difference by patient sex, language, race/ethnicity, or
insurance type.
A multivariate logistic regression revealed that younger age
group, UC visit (vs ED visit), prescriptions by a resident physician,
and those with a noninjury diagnosis were all independently associ-
ated with prescriptions with longer than a 5-day duration (Table 4).

DISCUSSION
This retrospective study of opioid prescribing over 1 year in
the pediatric EDs and UCs of a Midwestern children’s hospital
system found that, although the proportion of pediatric ED visits
FIGURE 1. Data abstraction.
in which an opioid was prescribed was relatively low (3%), the
proportion of those visits for which more than a 5-day supply
was prescribed was nearly 1 in 5. There is little data from other
hypothesized that injury diagnoses and English speakers would re- children’s hospitals available, so it is not known how these num-
ceive more opioids, and PEM physicians would prescribe less, so bers compare with other sites. One study looked at pediatric ED
these were also chosen as reference groups. All data were analyzed visits where an opioid was given or prescribed and found that this
in SPSS version 18 (IBM Corporation, Armonk, NY). was most frequent in the Western region and less frequent but sim-
ilar in the Northeast, Midwest, and South.24 However, they did not
RESULTS separate opioids given in the ED and prescribed for home, so we
There were a total of 4606 ED and UC visits identified by the cannot extrapolate based on these data. Factors associated with
electronic medical record as having an outpatient prescription for larger supplies prescribed were young patient age, UC setting, pre-
an opioid narcotic written during the study period. Four hundred scriptions by a resident physician, and noninjury diagnosis.
forty-eight were excluded because they were discontinued. There We defined our outcome as more than 5 days of opioid pre-
were a number of visits where several prescriptions were written scribed, which was consistent with existing ED guidelines that rec-
for the same encounter, and it could not be determined which pre- ommend between 3 to 7 days, depending on the state. The existing
scription was given; these 83 prescriptions were not included. This
left a total of 4075 available for analysis, or approximately 3% of all
ED and UC visits during the year (Fig. 1). Eighty percent originated TABLE 2. Demographics of the Study Population (total
in the ED and 20% from the UC. Demographic characteristics of N = 4075)
patients in the study mirrored our general patient population across
the included ED and UC sites with respect to language but were Variable n (%)
more likely to be older white males and commercially insured
(Tables 1 and 2). Pediatric emergency medicine physicians Sex
prescribed 16% of opioids. The pediatric and rotating (EM and Male 2306 (57)
family practice) residents they supervised were responsible for Female 1769 (43)
24% and 11% of the prescriptions, respectively. General Primary language
pediatricians wrote for 49%. Injury complaints accounted for 65% English 3816 (93)
of diagnoses, and noninjury, 35%. More specifically, the most Spanish 225 (6)
common diagnoses receiving an opioid prescription were fractures Other 34 (1)
(40%); skin complaints including burns, wounds, abscesses, and Race/ethnicity
skin infections (16%); and other orthopedic diagnoses including
White 2560 (63)
sprains, dislocations, and crush injuries (9%). Few prescriptions
(<1%) were written for children with medical conditions associated Black 775 (19)
with chronic pain of which the majority were for children with Hispanic 441 (11)
hemoglobinopathies (sickle cell disease, spherocytosis, etc). Other 299 (7)
Prescription Information Payment source
Government insurance 1776 (44)
Oxycodone and oxycodone-containing products accounted
for 93% of the prescriptions. The remaining 7% were composed Commercial insurance 1978 (48)
of hydrocodone, codeine, and products containing those opioids. Self-pay/other 321 (8)
There were no refills given on any of the prescriptions. Of the Age
4075 prescriptions, 84 were excluded for further analysis because <1 y 83 (2)
of insufficient information needed to calculate the number of days 1–4 y 992 (24)
supplied. Of the 3991 prescriptions in the analysis, the median 5–9 y 1180 (29)
number of days prescribed was 3.3 with an interquartile range of 10–14 y 1226 (30)
2.5 days and a total range of 1 to 44 days. A total of 721 (18%) >14 y 594 (15)
were written for more than a 5-day supply (Fig. 2).

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DePhillips et al Pediatric Emergency Care • Volume 00, Number 00, Month 2017

FIGURE 2. Number of prescriptions by length in days.

TABLE 3. Patient and Clinical Characteristics Associated With Opioid Prescriptions of More Than 5 Days’ Duration

Variable 0–5 d (n = 3270), n (%) >5 d (n = 721), n (%) P

Sex
Female 1401 (43) 332 (46) REF
Male 1869 (57) 389 (54) 0.12
Language
English 3069 (94) 671 (93) REF
Non-English 201 (6) 50 (7) 0.43
Race
White 2064 (64) 446 (62) REF
Nonwhite 1206 (36) 275 (38) 0.53
Payment source
Commercial insurance 1597 (49) 343 (47) REF
Government insurance 1407 (43) 336 (47) 0.21
Self-pay/none 266 (8) 42 (6) 0.08
Age
<1 y 40 (1) 41 (6) <0.001
1–4 y 597 (18) 371 (51) <0.001
5–9 y 973 (30) 180 (25) <0.001
10–14 y 1123 (34) 84 (12) 0.55
>14 y 537 (17) 45 (6) REF
Location
ED 2635 (81) 543 (75) REF
UC 636 (19) 178 (25) 0.002
Prescriber
PEM physician 538 (16) 98 (14) REF
General pediatrician 1565 (48) 374 (52) 0.03
Resident physician 1167 (36) 249 (34) 0.22
Diagnosis
Injury* 2299 (70) 416 (58) REF
Noninjury† 971 (30) 305 (42) <0.001
*Injury diagnoses include fractures, other orthopedic diagnoses (sprains, dislocations, crush injury), abrasions, contusions, wounds, burns, dental, eye,
and head injury.
†
Noninjury diagnoses include abscess or skin infection, ear or throat pain, oral lesions, and viral infections.
REF indicates reference group.

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Pediatric Emergency Care • Volume 00, Number 00, Month 2017
TABLE 4. Patient and Clinical Characteristics Associated With Opioid Prescriptions of More Than 5 Days’ Duration, Adjusted Odds
Ratio
Variable 0–5 d (n = 3270), n (%)
Age
<1 y 40 (1)
1–4 y 597 (18)
5–9 y 973 (30)
10–14 y 1123 (34)
>14 y 537 (17)
Location
ED 2635 (81)
UC 636 (19)
Prescriber
PEM physician 538 (16)
General pediatrician 1565 (48)
Resident physician 1167 (36)
Diagnosis
Injury 2299 (70)
Noninjury 971 (30)
*Adjusted for all other variables in the table.
REF indicates reference group.
acute care guidelines in New York City (NYC), Ohio, and Oklahoma
suggest limiting the prescription to a 3-day supply.15–17 Those in
Arizona and Washington suggest prescribing no more than
30 doses (5–7 days).18,19 Using 5 days may have resulted in a con-
servative estimate of the prevalence of prescriptions written for
prolonged duration. If we had defined prolonged duration as more
than 3 days per the Ohio, Oklahoma, and NYC guidelines, 56% of
prescriptions in this study would have met this definition.
In our study, the younger the patient, the more likely a greater
than 5-day supply of opioids was prescribed. Initially, we thought
this may be the result of a default dispense quantity (120 mL) for
liquid medications specific to our electronic prescribing system.
However, after removing all prescriptions written for 120 mL
and recalculating ORs, we did not find a difference in results or
significance from our original analysis. Perhaps some physicians
prescribe more liquid to account for spillage or spitting out of
medication. In addition, providers may be aware that adolescents
are at higher risk of misuse of opioids and therefore prescribe a
shorter duration to older children.25,26
There was an increased likelihood of a patient receiving more
than 5 days of opioids if the prescription was written by a resident
physician. A possible explanation for this is that compared with
PEM physicians resident physicians do not receive in-depth train-
ing or education on writing opioid prescriptions to children during
medical school or residency and may be unaware of updates on
the status of prescription opioid abuse, which circulate in EM
Listservs and in the EM literature.27 Also, resident physicians
can independently prescribe controlled substances in this state.
Our univariate analysis showed a significant relationship be-
tween general pediatricians and opioid prescriptions for more than
5 days (P = 0.03). However, this was found to not be significant in
our multivariate logistic regression (OR, 1.1; 95% CI, 0.9–1.5).
Although the cause of this is uncertain, we could postulate that
general pediatricians are more commonly prescribing opioids for
noninjury diagnoses as they see less injuries than do PEM pro-
viders, and by controlling for injury versus noninjury diagnosis
in the multivariate analysis, this was no longer found to be a
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Opioid Prescribing Practices
>5 d (n = 721), n (%) Adjusted OR* (95% CI)
41 (6) 12.3 (7.3–21.0)
371 (51) 7.7 (5.5–10.8)
180 (25) 2.4 (1.7–3.4)
84 (12) 0.9 (0.7–1.4)
45 (6) REF
543 (75) REF
178 (25) 1.4 (1.1–1.7)
98 (14) REF
374 (52) 1.1 (0.9–1.5)
249 (34) 1.4 (1.1–1.8)
416 (58) REF
305 (42) 1.4 (1.2–1.7)
significant predictor. We believe that this is still a good focus for
education because pediatricians also do not receive sufficient ed-
ucation on opioid prescribing.
Interestingly, patients with noninjury diagnoses were more
often prescribed more than 5 days of opioid analgesics compared
with those with injury diagnoses. The most common noninjury di-
agnoses included abscesses, ear and throat pain, viral illness, stoma-
titis, and abdominal pain. One possible reason is that providers may
view pain associated with these diagnoses as longer lasting than in-
jury diagnoses. There is minimal literature looking at how long pain
lasts in noninjury diagnoses, and therefore they may be prescribed
more than necessary. Further research is needed.
There was a large variability in the number of days of opioid
prescribed, which is consistent with the fact that guidelines for
opioid prescribing for acute care settings are few. Prescribing
guidelines exist for treatment of chronic, nonterminal pain includ-
ing those of the CDC, but few for acute pain.28 Examples of recent
guidelines for acute pain include those in NYC, Ohio, Oklahoma,
Arizona, and Washington.15–19 The American College of Emer-
gency Physicians released a clinical policy in 2012 addressing pre-
scribing of opioids for adults in the ED.29 The policy supports that
long-acting opioids should not be used for acute pain, and opioid
prescriptions should be written for less than 1 week. Missouri and
Kansas (the setting of this study) currently have no guidelines.
Limitations
One limitation of our study is the use of a deidentified ad-
ministrative data set, which precluded us from examining other
clinical factors likely related to the amount of opioid prescribed
such as the extent, severity, and nature of the injury/illness, as well
as specific prescriber information. Another limitation is generaliz-
ability. This study included 1 hospital system in the Midwest, so
the findings may not be applicable to other parts of the country.
All of the EDs and UCs studied are part of a children’s hospital
system, and all are staffed by pediatricians or PEM physicians.
There are other acute care settings where both adult and pediatric
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DePhillips et al
patients are cared for by EM or primary care physicians, and our
results may not be applicable because they may be more or less likely
to prescribe prolonged durations of opioids. Finally, in Missouri and
Kansas, it is legal for residents to write opioid prescriptions. This may
bias the results toward prolonged duration compared with states
where it is not legal for residents to prescribe opioids.
CONCLUSIONS
Nearly 1 in 5 opioid prescriptions written from our pediatric
EDs and UCs were for a prolonged duration, and prolonged pre-
scriptions were more frequently prescribed for younger patients,
written from the UC or by resident physicians, or written for non-
injury diagnoses. These findings can help suggest areas where
prescribing practices can be improved. Guidelines for opioid pre-
scribing should be developed for reference in the pediatric ED and
UC. Educational interventions including mandatory courses or mod-
ules on appropriate opioid prescribing in medical school and resi-
dency, as well as continuing medical education for all physicians,
should be required. Finally, we need to further evaluate our prescrib-
ing practices for common diagnoses. More studies are needed evalu-
ating the use of opioids at home for specific painful diagnoses to help
us tailor the dispense amount to only what is needed. By improving
our prescribing practices, we hope to decrease the amount of opioids
available for nonmedical use and abuse in the home and community.
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