Incidence and patterns of persistent opioid use in children following appendectomy


      • Patterns of persistent opioid use following appendectomy have not been previously elucidated.
      • This study further defines risk and patterns of chronic opioid use in publicly insured children following appendectomy.
      • 7.1% of children have persistent opioid use following appendectomy, 80.3% of whom were opioid naive.



      The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children.

      Study design

      A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis.


      1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions.
      Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%).


      Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population.

      Level of evidence


      Graphical abstract



      APAP (N-acetyl-para-amino-phenol (acetaminophen)), BIC (Bayesian Information Criterion), CI (confidence interval), EP (exposure period), GLM (generalized linear model), GBTM (group-based trajectory models), MME (morphine milligram equivalent), NSAIDs (nonsteroidal anti-inflammatory drugs), PCP (primary care provider), RFA (Revenue and Fiscal Affairs Office)
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