Melanie Cole, MS (Host): Welcome to Pediatric Frontlines by Shriners Children's. I'm Melanie Cole, and according to the CDC, the rate of opioid overdose deaths among individuals, 15 to 24, increased by 700% from 1999 to 2022. Per the National Institutes of Health, high school students who legitimately use prescription opioids are 33% more likely to misuse them after high school. Today we're highlighting a new approach to the problem of pain and the latest breakthroughs in pediatric pain management. Joining me today is Dr. Selina Poon. She's a Pediatric Orthopedic Surgeon at Shriners Children's Southern California.

Dr. Poon, thank you so much for joining us today and this is a great topic and something that we are learning more and more and as pediatric pain is often under recognized or underappreciated, how has our understanding of pediatric pain physiology different than adult physiology? How has that evolved in recent years and how has it evolved more importantly, beyond symptom control and into a truly patient centered model?

Selina Poon, MD, MPH, MS: Yeah, so you know, you're talking about pediatric pain with an orthopedic surgeon, right? So this is what is different at Shriners is that we actually really do care about the entire patient. So, I like to say because I operate on kids that kids are not mini adults. Their whole physiology is very different from an adult physiology.

So not only do they have growth plates, the way they clear medication, their lungs, their kidneys, all of that is all very different. And so we have a team of like very involved researchers who are anesthesiologists, who love, who loves, like looking into this question. And so here we've done a bunch of research projects just looking into how do we control pain for patients, in addition to just medication.

Because we know that as surgeons, we have put out a lot of prescriptions out there. And so, young kids get exposed, young kids who have surgery get exposed to medications, opioids, and then they're more likely to proceed and then maybe use opioids in the inappropriate way post. So the less we can leave out there, the better off we are.

So we've looked at how we prescribe, we've looked at how we take it back, and we've looked at how the patients can actually get rid of medications. And in addition how we give it out during their surgery and how they are given and controlled intraop and postoperatively. So we take a whole picture of the opioids and pain control and so that we have a whole picture of how we can help this entire problem.

Melanie Cole, MS (Host): Well, it certainly is a burgeoning field, and you've said that Shriners Children's Southern California has led the way in the system regarding pain control, opioids and perioperative pain management. Tell us a little bit about that and where in this line they do come in and then we're going to get into stewardship in just a little bit too.

Selina Poon, MD, MPH, MS: Yeah. So, I work for the Shriners Children's Southern California, but I do say that this is an entire system-wide opioid stewardship. What started here is that, one of our anesthesiologists is very keen on looking at pain. And so he decided to start like, well, instead of just giving out medication, we should ask the patient, how much medication they're taking. In addition, he actually like taught me or made me remember, first order pharmacokinetics. Those are words that came outta the pediatric orthopedic surgeon's mouth, and I had to go back. All the way back to medical school to remember pharmacology and what that means. And what he told me, or he reminded me of is that medication that we take takes time to kind of built up in our blood levels and it takes about five doses of medication for our blood level to get to a steady state. So that's about two days ahead of surgery. So what he has decided, or implemented years ago, at least in our local Shriners, here in Pasadena, is that he decided to start giving pre non-opioid medication two days before, and that includes an anti-inflammatory, a gabapentin, so that we can preemptively limit the pain before I even start the surgery.

And that has actually proven for ourselves, and we've actually published on this, that it does decrease the pain, and it maybe decreases the length of stay as well.

Host: Well, thank you for telling us, because many people don't know what first order pharmacology really means. And so tell us a little bit about the latest findings regarding the use of non-pharmacologic interventions as we look today at that stewardship and that multimodal approach that is so important.

And especially in pediatric, in pediatric and pain management. Tell us a little bit about what you're doing.

Selina Poon, MD, MPH, MS: Yeah, so everybody is all about the preemptive medication and we're the only one who does it two days ahead. And that's because of the pharmacology. But most people have at least, the day, the night before, the day before, and there's all kinds of medication. What here in Shriners is that we actually have our Child Life specialists helping us before the surgery, and our Child Life specialists are actually researchers as well. And they have gotten the grant through the Pediatric Orthopedic Society of North America looking at anxiety before surgery. And what our Child Life specialists have done is that they have created a video for our patients so that they can see like exactly what they're going to go through. They can see the operating room beforehand, they can see the pre-op, they can see the post-op.

And they have actually proven in a research study that is published that it actually decreases the patient and their providers, I mean, their guardians' anxiety post-op and decreases their behavior malfunctions post-op too. So like preparing them, giving them the tool to see what's going to happen actually helps our patients so that it, on top of just medications, we have our Child Life specialists really involved as well.

Host: Tell us about the new text-based system that you're implementing.

Selina Poon, MD, MPH, MS: Yeah. So, this is also, we're trying to look at things a different way, and as researchers we've always just kind of looked at, how much pain medicine are people taking? And what we've done previously is ask the patients during their post-op visit, like, how many medications have you taken?

And then we do ask them to bring back the pill and, some of them bring it back, some of them don't, that don't bring it back, and then therefore we can count pills with them. But, it's still based on recall. It's still based on like, well, I think I took two. Maybe three, and then we ask them to actually write it down.

But like, we are very busy, so we're like, we don't always have that log, the pill logs with us, so we're not always accurately recording it. So now the system has looked into a text-based system where we actually send a text to the guardians of the patient every day. How's your pain? How many pills have you taken?

Is it controlled? What else can we do to help you? And then our anesthesiologists have that data and so they can actually respond in real time if, necessary. So I think this is going to also give us exactly how many pills they're taking. So instead of me writing, oh, 30 pills for a big surgery, 10 pills for a small surgery, two pills or zero pills for a very, very minor surgery, we're going to actually get back data saying, Hey, for this surgery you on the average, your patients have used 10 pills. And so as we transition to Epic, and with Epic, we can actually go order sets. Research have shown that physicians like things easy. So if you give me an order set saying your post-op orders, here's the order set with 10 opioid pills per patient that you do surgery on, I will more likely click on that.

And if I think my patients need more or less, I can alter it. But because there's an order set it decreases the variability of what we order in general for our patients. And so that's how we're going to look at whether we can actually decrease the number of opioids that are being given out or the prescriptions that are being given out.

Host: That's so interesting, and while we're talking about this multimodal approach and even looking at opioid stewardship, which we know is so important as this evolves. Another important point is the concept of that multidisciplinary approach in pediatric pain, orthopedics specifically. Tell us a little bit about who's involved in such a team and why that's so important as we look at these levels of pain.

Selina Poon, MD, MPH, MS: Of course. So, in adults, as surgeons, most of the time, who is writing the prescription is the surgical team, right? Like it's either me or my residents or my PA is writing the post-op orders and we're just writing it out. Luckily, for us, we have anesthesiologists who are super involved and want to do the best for our patients.

And so actually our anesthesiologists here in Pasadena actually see them pre-op and see them post-op. And they are actually writing the prescriptions and they're managing their pain. And so who better to manage pain than an anesthesiologist? Who, in knows the patient who go, takes them through surgery and then sees them post-op to make sure their pain is well controlled and they do the blocks as well pre-op, just to make sure like, Hey, this is how we're going to limit your pain. Please take the pain medicine at the appropriate time, so when the block wears off, we are ahead of the game and not just waiting for you to have too much pain before we go. And so they write their pre-op medication, they do their surgery, they do the block, and then post-op, they are managing the pain.

That's number one. Number two, we have obviously our Child Life specialists who are involved pre and post-op. And then our pediatricians are very, very involved as well, and they participate in our pre and post-op conference, making sure that we're safe, making sure like we're not overmedicating the patients, all of that. So that is our team for pain management.

Host: You mentioned the text-based system, which is just awesome. How else Dr. Poon are families for the pediatric patients involved, how do you incorporate them and educate them? I mean, when their child has to have surgery, they're learning along with the child about what to expect, what's going to happen afterwards, and that pain management plan.

Selina Poon, MD, MPH, MS: Yeah, so the anesthesiologist actually talks to them beforehand and post, and actually our anesthesiologists are good enough to give them their cell phone numbers. So, so they can like, just in case they can reach somebody. And I feel like people, parents and patients, once they realize that they have somebody they can call if they need to, then the anxiety goes down.

And anxiety and pain are very connected. And so that's, how they do that. In addition, we actually post-op, we have, we give them a post-op mixture where they can use this mixture, dump it into their post-op opioids, once they're done, shake it up. And then, we have an environmentally friendly way of getting rid of your opioids so it doesn't sit in your cabinet for somebody else to get into.

And so that was another research project that we embarked upon to make sure that our patients are not having leftover opioids for diversion, where other people can get into or, they can actually get into themselves, in case.

Host: Are there any recent developments, Dr. Poon, in personalized pain management strategies for pediatric patients that you'd like to discuss?

Selina Poon, MD, MPH, MS: So what we have noticed recently, this is our newest project that we're kind of looking into, is that weed and cannabis is now legal in certain states and not legal in other states. But we want to know like what happens and how often this affects the patients because some of the adult literature are coming out to show that pain control is worse with patients who have recently taken cannabis and their intraop, like during surgery, it's harder to control their pain. So we don't know anything about pediatrics and like I said at the beginning, adults and kids are very different. And so this is where we're going to go with our next project, is to look at that. We're going to somehow, we're going to ask our patients as we do pre-op for everything that we do to make sure that they don't have any drugs when we do a drug screen and we want to make sure that they're, they don't have any drugs on board or, we would have to cancel the surgery, but we don't usually cancel surgery for cannabis. And so that is something that we want to look at.

We want to see whether having done any kind of cannabis before surgery is going to affect their intra-op management. So the anesthesiologist will then look at like how much pain medicine they need based on the surgery that they have since we have baselines now and then, post-op, do they need more pain medicine just to make sure that their pain is controlled.

And so I'm super excited and we, we have this text based system as well. So that'll give us a really good way to look at this data. And so, Dr. Patel, who is our anesthesiologist is, spearheading that project. And we have submitted this grant to be funded.

Host: Dr. Poon, what an interesting topic this is, and what you're doing is such important work. And if you could convey one message and takeaway, a key takeaway from this discussion that we're having here today for other clinicians about transforming that culture of pediatric pain management for other clinicians, what would you like those key takeaways to be?

Selina Poon, MD, MPH, MS: I think we need to keep asking questions, right? Like we can always improve on what we do and how we do it, and this is what this team here has done, is that we keep, just keep asking questions, how can we do this better? How can we take care of this patient better? How can we decrease the number of opioids that they're taking. Can we do blocks? Can we look at how different medication is affecting everybody? And so we're trying to a little bit standardize how we treat patients in the system. So we've looked at how various different strategies of post-op pain management control and what, which one works, right? So this is where we are going to be the leader in the field because the Shriner system is a system in the United States, Mexico and in Canada. So we have vast amounts of data and once we start collaborating and now that we are able to collaborate and really, really look at the data together; we're going to be able to make real differences.

And so I, for all the other clinicians, just stay curious. Like we can always make things better, and this is why research nerds like me work in places like this is that we can actually find the answers.

Host: That was so well said. Dr. Poon, thank you so much for joining us today and sharing your incredible expertise for other providers. Thank you so much again, and for more information, including the full range of care disciplines, please visit shrinerschildren's.org. And to hear more Pediatric Frontlines episodes, please subscribe wherever you listen to your podcasts. I'm Melanie Cole. Thanks so much for joining us today.

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