Experts warn about opioids post tonsillectomy

In the U.S., 289,000 children aged 15 years and younger receive a tonsillectomy each year, making it one of the most common surgeries.¹ The procedure completely removes the tonsils and is sometimes performed along with adenoidectomy, which is surgery to remove the adenoids.

While tonsillectomy itself is associated with serious long-term risks,² parents need to be aware that the painkillers given to children following the surgery can also be dangerous. This is especially true if children are prescribed opioids, powerful pain-relieving drugs linked to an epidemic of overdose deaths.

In a revealing study from University of Michigan’s C.S. Mott Children's Hospital researchers, 59.6% of children received a prescription for opioids following tonsillectomy,³ even though safer pain relief options would likely have worked just as well.

Six in 10 children prescribed opioids after tonsillectomy

Data from 15,793 children aged 1 to 18 who underwent tonsillectomy were analyzed for the study, revealing that 6 in 10 had at least one prescription for opioids filled following the procedure. Yet, there was no difference found in risk of return visits for pain or dehydration among children taking opioids or non-opioid drugs.⁴

Taking opioids was associated with an increased risk of constipation and opioid overdose.⁵ What’s more, the median prescription duration was eight days, which could mean an equivalent of 48 doses of the drugs — more than is typically needed. Past research found that an average of 52.2 doses of opioids may be prescribed to children following a tonsillectomy, with an average of 43.8 leftover doses.⁶

Not only does this increase the risk of adverse effects and addiction, but it poses a risk for family and friends who may take the leftover pills.⁷ According to the study authors:⁸

“Most children received less than 50% of their prescribed opioid doses because parents quickly tapered opioids, switched to nonopioids, or discontinued analgesics during the first few postprocedure days.

This left a considerable amount of unused prescribed opioids in the homes of children who were prescribed these agents for acute pain. This suggested mismatch between dispensed and used prescription opioids can inadvertently contribute to risky behavior and, therefore, begs for broad intervention.”

As for why opioids are often prescribed following tonsillectomy, the University of Michigan researchers suggested they’re often believed to provide superior pain relief and reduce the risk of return visits to the doctor, but this study suggests this isn’t the case.

They’re also sometimes offered over nonsteroidal anti-inflammatory drugs (NSAIDs) due to concerns that NSAIDs may increase the risk of bleeding, but research suggests they can be used safely following tonsillectomy.⁹

“Our findings suggest that it may be possible to reduce opioid exposure among children who undergo this common surgery without increasing the risk of complications,” lead author Dr. Kao-Ping Chua said in a news release, adding:¹⁰

“To minimize the risks of opioids to children and their families, clinicians should rely on non-opioids when possible. When opioids are used, they should aim to prescribe only the amount that patients need …

However, our study suggests that many children receive opioid prescriptions after tonsillectomy and that the amount may be excessive. We need to conduct research to identify interventions that safely and effectively reduce opioid exposure for these children.”

Otolaryngologists advise against opioids after tonsillectomy

Prescription opioids are sometimes considered standard care for treating severe pain in adults following surgery or injury or due to illnesses such as cancer, although they’re now increasingly prescribed for many types of pain, including chronic back pain or pain from osteoarthritis.

The American Academy of Otolaryngology-Head and Neck Surgery (AAO HNS), however, advises against their use after tonsillectomy, advising instead, “Clinicians should recommend ibuprofen, acetaminophen or both for pain control after tonsillectomy.”¹¹ In their plain language summary for patients, AAO HNS further states:¹²

“Some medicines like antibiotics and codeine (koh-DEEN) or any medication containing codeine are not good for children younger than 12 years after tonsillectomy. There are better choices than codeine even for children 12 to 18 years old. Codeine [an opioid] can cause very slow breathing and, if too much is given, death. It can also be habit forming (addictive).”

Opioids given to children despite FDA black box warning

In 2012, the FDA announced it was reviewing the safety of codeine use after tonsillectomy and/or adenoidectomy after serious adverse events and deaths were reported.

They found many of the children affected had obstructive sleep apnea and “had evidence of being ultrarapid metabolizers of codeine, which is an inherited (genetic) ability that causes the liver to convert codeine into life-threatening or fatal amounts of morphine in the body.”¹³

“Since these children already had underlying breathing problems, they may have been particularly sensitive to the breathing difficulties that can result when codeine is converted in the body to high levels of morphine,” the FDA announced.¹⁴

“However, they continued, “this contraindication applies to all children undergoing tonsillectomy and/or adenoidectomy because it is not easy to determine which children might be ultrarapid metabolizers of codeine.”

The end result was a black-box warning, the FDA’s strongest warning, added to the label of codeine-containing products advising against the use of such drugs in all children following tonsillectomy and/or adenoidectomy. 

In 2017, Chua and colleagues published a study that found the FDA’s investigation significantly reduced codeine prescribing to children after these procedures — but did not stop it entirely. In a review of 362,992 children who underwent tonsillectomy and/or adenoidectomy, 5.1% had one or more prescriptions for codeine filled in December 2015.

The researchers explained, “1 in 20 children undergoing these surgeries were still prescribed codeine in December 2015 despite its well-documented safety and efficacy issues.”¹⁵

Considering the risks of prescribing codeine to children, the inability to identify which children may be especially vulnerable to its effects and the widespread availability of nonopioid pain relief options, the researchers described prescribing codeine to children after tonsillectomy an “unnecessary gamble, “particularly for children with OSA [obstructive sleep apnea], who are at a higher risk for opioid-related respiratory depression.”¹⁶

Parents mistakenly believe opioids are best for pain

Despite widespread media headlines highlighting the risks of opioid abuse and overdose deaths, many parents still believe they’re the most effective option for pain relief. In a survey commissioned by the American Society of Anesthesiologists, nearly two-thirds of parents surveyed believed opioids were better for pain management after surgery or a broken bone than alternatives.¹⁷

In reality, research published in the Journal of the American Medical Association (JAMA) suggests that less risky opioid-free options may work just as well.¹⁸

The study evaluated the effects of four different combinations of pain relievers — three with different opioids and one opioid-free option composed of ibuprofen (i.e., Advil) and acetaminophen (i.e., Tylenol) — on people with moderate to severe pain in an extremity, due to bone fractures, shoulder dislocation and other injuries.

The patients had an average pain score of 8.7 (on a scale of zero to 10) when they arrived. Two hours later, after receiving one of the pain-relief combinations, their pain levels decreased similarly, regardless of which drug-combo they received. Specifically, pain scores fell by:¹⁹

• 4.3 in the ibuprofen and acetaminophen group
• 4.4 in the oxycodone and acetaminophen group
• 3.5 in the hydrocodone and acetaminophen group
• 3.9 in the codeine and acetaminophen group

“For patients presenting to the ED [emergency department] with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at two hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics,” the researchers concluded.²⁰

Opioid-related deaths among children nearly triple

The opioid epidemic kills 130 Americans daily,²¹ and sadly this sometimes includes children. While adult deaths due to opioid overdose have trended upward in recent years, so too have those among children.

From 1999 to 2016, 8,986 children and adolescents died due to opioid poisonings — an increase in mortality rate of 268.2%.²² Prescription opioids were responsible for 73% of the deaths, with the mortality rate increasing 131.3% during the study period.²³

According to the study, “These findings suggest that the opioid epidemic is likely to remain a growing public health problem in the young unless legislators, public health officials, clinicians and parents take a wider view of the opioid crisis and implement protective measures that are pediatric specific and family centered.”²⁴

The findings underscore the high risks involved when bringing opioids into your home and highlight the importance of choosing the least dangerous pain relief option available following surgeries like tonsillectomy.

If your child is scheduled to have this procedure, ask his or her doctor about pain relief options and express your desire for a nonopioid option. However, before choosing to have your child’s tonsils removed, be aware that the surgery itself is risky and may not be the best option for your child.

Risks of tonsillectomy may outweigh benefits

Tonsillectomies are often recommended for treatment of recurring, chronic or severe tonsillitis or complications resulting from enlarged tonsils, such as difficulty breathing at night.²⁵ However, the benefits of the surgery may not outweigh the risks, according to a population-based cohort study of 1,189,061 children.²⁶

In estimating the long-term disease risks associated with tonsillectomy in childhood, the researchers evaluated data from children who had their adenoids or tonsils removed within the first nine years of life, finding their removal to be associated with a significantly increased risk of respiratory, allergic and infectious diseases later in life.

“Increases in long-term absolute disease risks were considerably larger than changes in risk for the disorders these surgeries aim to treat,” the researchers explained.²⁷ Far from being superfluous tissue, your tonsils and adenoids play an important role in the development and function of your immune system, helping to protect against pathogens and stimulate immune response.²⁸

Short-term risks of tonsillectomy, meanwhile, also carry risks, including severe bleeding before or after surgery, swelling that can cause breathing problems, infection and reactions to anesthetics.²⁹

In some cases, a tonsillotomy, or partial removal of the tonsils, may be an alternative surgical option for both children and adults; however, parents should carefully consider whether surgery is the best option to resolve the underlying medical condition.

Finally, if you, your child or someone you love has chronic pain of any kind, know that there are many safe and effective alternatives to prescription and even over-the-counter painkillers that provide excellent pain relief without any of the health hazards that pain medications like opioids often carry.