Dr. Groenewald is Director of Pediatric Anesthesiology Research at Stanford University School of Medicine. He conducts clinical research that crosses several areas related to child health, including epidemiology, health services research, pediatric pain, sleep deficiency, and opioid use behaviors. His research is funded by the National Institutes of Health, International Association for the Study of Pain, and the Society for Pediatric Anesthesiology. His work on pediatric pain, sleep disturbance, and opioid use has been published in JAMA Pediatrics, Pediatrics, PAIN, Journal of Pain, SLEEP, and JAMA Psychiatry. Dr. Groenewald holds national leadership positions in the United States Association for the Study of Pain, including being elected as inaugural Chair of the Pediatric Special Interest Group in 2020 and co-chair of the Advocacy committee in 2022. He serves on the editorial boards of the Journal of Pain and Pediatric Anesthesiology.

Clinical Focus

  • Anesthesia

Academic Appointments

Administrative Appointments

  • Director of Pediatric Anesthesiology Research, Stanford University School of Medicine (2023 - Present)

Boards, Advisory Committees, Professional Organizations

  • Co-Chair, Advocacy Committee, United States Association for the Study of Pain (2023 - Present)
  • Editorial Board, Pediatric Anesthesia (2023 - Present)
  • Chair, Pediatric Special Interest Group, United States Association for the Study of Pain (2021 - 2023)
  • Editorial Board, Journal of Pain (2019 - Present)
  • Organizing Committee, United States Association for the Study of Pain (2019 - 2021)

Professional Education

  • Board Certification: American Board of Anesthesiology, Anesthesia (2023)
  • Board Certification: American Board of Anesthesiology, Pediatric Anesthesiology (2015)
  • Research Fellowship, Seattle Children's Hospital and the University of Washington, Seattle, WA (2013)
  • Fellowship, Seattle Children's Hospital and the University of Washington, Seattle WA (2012)
  • Residency, Mayo Clinic, Rochester MN (2011)
  • Medical Education, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa (2002)


  • Sleep Disturbances and Long-term Outcomes after Critical Illness in Children (K23HL138155), National Heart, Lung, and Blood Institute (NHLBI,NIH), Seattle Children's Hospital and University of Washington, Seattle WA (2017 - 2023)

    Annually 250,000 critically ill children are admitted to 350 pediatric intensive care units (ICUs) in the United States. Most (>97%) survive, however many critical illness survivors suffer significant long-term health impairments that result in lower quality of life (HRQL) and increased health care use. Acute sleep deficiency is common following critical illness. However, limited knowledge exists of the potential impact of deficient sleep on markers of health following critical illness such as physical and mental health, HRQL, or health services utilization. Thus, the primary objective of this proposal is to systematically document for the first time the impact of sleep deficiency on health, quality of life, and health care utilization in children surviving critical illness. The central hypothesis is that sleep deficiency persist and negatively impact health following critical illness.

    The research plan involves 2 studies: 1) a prospective cohort study using objective and subjective measures of sleep over 12 months in children with critical illness and controls (80=critically ill and 40=age and sex matched controls)(study 1), and 2) a qualitative study to understand child and parent perspectives on managing sleep deficiency following critical illness (study 2). Primary aims are to 1) characterize the nature, trajectories, and impact of sleep deficiency experienced by children following critical illness (study 1), 2) identify risk factors associated with persistent sleep deficiency over 12 months in children following critical illness (study 1), and 3) identify, directly from children and their parents, perspectives on the barriers and facilitators of implementing interventions to manage sleep deficiency following critical illness (study 2).


    Seattle, WA

  • Sleep deficiency and opioid use/misuse in adolescents following surgery (R01HL166337), National Heart, Lung, and Blood Institute (NHLBI, NIH), Stanford University School of Medicine (2023 - 2028)

    Prescription opioid misuse is a significant burden on adolescent public health in the United States. Opioid misuse often starts with prescribed opioids, with surgery representing a key pathway by which adolescents are first prescribed opioids for the management of acute pain. Yet, little is known about the critical period following surgery during which adolescents initiate prescription opioid misuse or the modifiable behavioral mechanisms contributing to this process. These are critical gaps in our knowledge impeding our ability to identify adolescents at increased risk for opioid misuse and to develop interventions aimed at reducing prescription opioid misuse.

    Sleep deficiency (including sleep deprivation, noncircadian sleep, sleep disorders, and poor sleep quality) is an important proximal risk factor for prescription opioid misuse. Sleep is often disturbed during the perioperative period, a time when many adolescents are exposed to their first opioid prescription. Indeed, in our own preliminary study, we found that sleep deficiency present both before surgery and during the immediate postsurgical period was associated with increased opioid use. However, this pilot study did not allow us to characterize aspects of sleep most strongly related to opioid use and did not allow us to evaluate mechanisms, such as pain and psychological factors, underlying the sleep – opioid use relationship. Furthermore, data are urgently needed to determine how sleep deficiency prospectively predicts the development of opioid misuse behaviors in the context of other putative factors, such as a history of substance use, pain intensity, psychosocial (e.g., depression), peer, and family factors. Given that sleep deficiency is modifiable, it is a critical focus of research aimed at reducing the development of adolescent opioid misuse behaviors.

    Therefore, this project aims to 1) test the direct and mediation pathways of sleep deficiency, pain, psychological factors, and opioid use following sports-injury surgery, and 2) develop and validate a multivariable prediction model to identify adolescents at increased risk of prescription opioid misuse over the 24 months following surgery. To address these aims, we propose a prospective, observational study of N= 400 adolescents (10-19 years) who receive their first ever opioid following sports injury surgery. Presurgery, participants will undergo comprehensive multimodal sleep assessments (surveys and actigraphy monitoring) to measure sleep deficiency. Participants will also report on previous substance use, pain intensity, psychosocial, peer, and family factors. Adolescents will then be followed over the first 14 days after surgery using ecological momentary assessment to capture real-time daily data on sleep, pain, psychological factors, and opioid use. We will use an innovative electronic medication monitoring methodology to accurately measure opioid use (total number of doses and duration) following surgery. Follow-up assessments at 3-months, 6-months, 12- months, and 24-months will track opioid misuse developing over time. We will apply modern machine learning algorithms to develop and validate models predicting adolescent prescription opioid misuse.


    Stanford CA

All Publications

  • Reply to Long-Mills and Tumin. Pain Kapos, F. P., Vandeleur, D. M., Tham, S. W., Palermo, T. M., Groenewald, C. B. 2024; 165 (6): 1425

    View details for DOI 10.1097/j.pain.0000000000003233

    View details for PubMedID 38739768

  • Influence of chronotype on pain incidence during early adolescence. Pain Li, R., Groenewald, C., Tham, S. W., Rabbitts, J. A., Ward, T. M., Palermo, T. M. 2024


    During adolescence major shifts in sleep and circadian systems occur with a notable circadian phase delay. Yet, the circadian influence on pain during early adolescence is largely unknown. Using 2 years of data from the Adolescent Brain Cognitive Development study, we investigated the impact of chronotype on pain incidence, moderate-to-severe pain, and multiregion pain 1 year later in U.S. adolescents. Based on the Munich ChronoType Questionnaire, chronotype was calculated as the midpoint between sleep onset and offset on free days, corrected for sleep debt over the week. Adolescents reported pain presence over the past month, and if present, rated pain intensity (0-10 numerical rating scale; ≥ 4 defined as moderate-to-severe pain) and body site locations (Collaborative Health Outcomes Information Registry Body Map; ≥2 regions defined as multiregion pain). Three-level random intercept logistic regression models were specified for each pain outcome, adjusting for baseline sociodemographic and developmental characteristics. Among 5991 initially pain-free adolescents (mean age 12.0 years, SD 0.7), the mean chronotype was 3:59 am (SD 97 minutes), and the 1-year incidence of pain, moderate-to-severe pain, and multiregion pain was 24.4%, 15.2%, and 13.5%, respectively. Each hour later chronotype at baseline was associated with higher odds of developing any pain (odds ratio [OR] = 1.06, 95% confidence interval [CI] = 1.01, 1.11), moderate-to-severe pain (OR = 1.10, 95% CI = 1.05-1.17), and multiregion pain (OR = 1.08, 95% CI = 1.02-1.14) during 1-year follow-up. In this diverse U.S. adolescent sample, later chronotype predicted higher incidence of new-onset pain.

    View details for DOI 10.1097/j.pain.0000000000003271

    View details for PubMedID 38809249

  • Sexual orientation/gender identity discrimination and chronic pain in children: A national study. American journal of preventive medicine Weiss, K. E., Li, R., Chen, D., Palermo, T. M., Scheurich, J. A., Groenewald, C. B. 2024


    This study provides national estimates of parental perceived child sexual orientation or gender minority (SGM) discrimination and examines associations between SGM discrimination and chronic pain in children.Cross-sectional analysis of the 2020 and 2021 National Survey of Children's Health (NSCH) (N=47,213). Caregivers of children ages 6-17 years old reported whether their child had ever been treated or judged unfairly (i.e., discrimination) because of their SGM identity. Chronic pain in children was defined as frequent or chronic difficulty with repeated or chronic physical pain during the past 12 months, as reported by caregivers. Weighted prevalence estimates for discrimination were calculated for the whole sample and sociodemographic subgroups. Associations between SGM discrimination and chronic pain were estimated using multivariable Poisson regression models adjusting for sociodemographic factors. Analyses were conducted 2022-2023.Within this nationally representative sample, parents reported 1.4% (95% CI: 1.2-1.6%) of children have experienced SGM-related discrimination. The prevalence was higher among adolescents, females at birth, and those living in suburban areas. Children who experienced discrimination had a higher prevalence of chronic pain (20.2%) compared to those who did not (7.0%, p<0.0001), with an adjusted prevalence rate ratio (aPR) of 2.0 (95% CI: 1.5-2.5, p<0.0001).Based on parent report, about 0.6 million children in the U.S. have experienced SGM-based discrimination; these children are twice as likely to have chronic pain. Findings highlight the importance of assessment and intervention for chronic pain in children who may experience marginalization and discrimination due to their sexual orientation and gender identity.

    View details for DOI 10.1016/j.amepre.2024.03.010

    View details for PubMedID 38508423

  • Prescription Opioid Decision-Making and Use Behaviors in Adolescents with Acute Pain: A Qualitative Study. The Clinical journal of pain Kapos, F. P., Gordon, G. O., Groenewald, C. B., Slack, K., Wang, V., Palermo, T. M., Wilson, A. C., Rabbitts, J. A. 2024


    Understanding adolescent perspectives on prescribed opioids in the context of medical care for acute pain is needed to prevent opioid-related adverse outcomes. We explored factors that may influence opioid decision-making and use behaviors among adolescents prescribed opioids for acute pain.We conducted semi-structured interviews with nineteen adolescents (63% females, ages 12-17) prescribed opioids upon discharge from surgery or intensive care unit admission. Interview transcripts were coded using inductive thematic analysis.Five themes were identified: "Opioid use to reduce extreme pain and facilitate acute recovery"; "Familiarity with risks and negative effects of opioids"; "Assessment of opioid risk based on individual characteristics and use behaviors"; "Careful balance of risks, benefits, and symptoms when taking opioids"; "Importance of trusted adults for adolescent opioid management". Adolescents commonly believed opioids are only appropriate for severe pain that cannot be managed with other strategies. Most (but not all) adolescents were aware of addiction and other potential opioid harms, and generally disapproved of misuse. However, a few adolescents would consider taking unprescribed opioids for severe pain. Adolescents wanted to be well informed for opioid decision-making, considering guidance from trusted adults.Adolescents often demonstrated active and sound participation in shared opioid decision-making, influenced by complex integration of inputs and self-reflection. Conversely, potential factors that could contribute to risky behaviors included low personal risk perceptions, uncertainty about what constitutes opioid misuse, and avoidance of prescribed opioids despite extreme pain. Future studies may explore associations of adolescents' opioid decision-making with longer-term pain and opioid-related outcomes.

    View details for DOI 10.1097/AJP.0000000000001205

    View details for PubMedID 38347761

  • Association of Neighborhood Characteristics and Chronic Pain in Children and Adolescents in the United States. The Clinical journal of pain Vandeleur, D. M., Cunningham, M. M., Palermo, T. M., Groenewald, C. B. 2023


    To determine the associations between neighborhood characteristics and chronic pain during childhood and adolescence in the United States, 2020-2021.Cross-sectional analysis of the 2020 and 2021 National Survey of Children's Health (NSCH). NSCH grouped parents' responses to questions about neighborhood characteristics into five categories: neighborhood support, neighborhood safety, school support, neighborhood amenities, and presence of detracting neighborhood elements. Chronic pain was defined as parents reporting their children had "frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain during the past 12 months." Multivariable Poisson regression analyses estimated associations between neighborhood characteristics and chronic pain, adjusted for sociodemographic characteristics.The sample contained 55,387 children (6-17 years), weighted to represent 44 million nationally. Children had significantly increased rates of chronic pain if they lived in neighborhoods that were unsupportive, unsafe, had unsafe schools, fewer amenities, and greater numbers of detracting elements (P<0.0001). After adjusting for covariates, children had significantly increased chronic pain if they lived in neighborhoods that were not supportive (adjusted prevalence rate ratio=1.7, (95% Confidence interval: 1.5-1.9, P<0.0001), with similar patterns observed for living in neighborhoods characterized as not safe, that did not have safe schools, with fewer amenities, and/or more detracting elements.Disadvantageous neighborhood characteristics are associated with pediatric chronic pain prevalence. Future research should investigate underlying mechanisms of this association, and guide neighborhood interventions aimed at preventing and decreasing childhood chronic pain and its associated burdens.

    View details for DOI 10.1097/AJP.0000000000001179

    View details for PubMedID 38013473

  • Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020. Paediatric anaesthesia Sofia, J. T., Kim, A., Jones, I., Rabbitts, J. A., Groenewald, C. B. 2023


    The United States currently faces an epidemic of opioid misuse which extends to adolescent surgical populations. Opioid prescriptions after surgery are associated with persistent opioid use and serve as a reservoir for diversion. However, it is unclear what proportion of opioid prescriptions are surgical, and little is known about trends in opioid prescription rates associated with surgery in adolescents in the United States. This study aims to describe national trends in postsurgical opioid prescription rates over time among adolescents in the United States.We conducted a population-based cross-sectional analysis of data captured in the Medical Expenditure Panel Survey (MEPS) from 2015 to 2020. MEPS classified adolescents 10-19 years of age (n = 26 909) as having a surgical procedure if they had any inpatient, outpatient, or emergency department visit during which a surgical procedure was performed.Mean age (SD) of the sample was 14.4 (0.01) years. Sociodemographic characteristics were representative of the USA adolescent population. In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%-3.7%, p < .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020).Opioid prescription rates associated with surgery remained stable between 2015 and 2020 in the United States, despite significant decreases in prescribing among nonsurgical populations. Surgery is now a leading source of medical prescribed opioids among adolescents. Secondary findings included a stable trend in surgery utilization between 2015 and 2020, as well as continued racial disparities, both in terms of surgery utilization and opioid prescribing.The large number of adolescents being prescribed opioids for surgery in the USA each year, suggests there is a need for national guidelines aimed at adolescent opioid use, similar to the recent CDC guidelines aimed at adult opioid use.

    View details for DOI 10.1111/pan.14753

    View details for PubMedID 37789737

  • Comparing the prevalence of chronic pain in school-aged children in the United States from 2019 to 2020: a nationally representative study examining differences associated with the COVID-19 pandemic. Pain Kapos, F. P., Vandeleur, D. M., Tham, S. W., Palermo, T. M., Groenewald, C. B. 2023


    The coronavirus disease 19 (COVID-19) pandemic negatively affected children's health in the United States (US), with more severe disruption for marginalized groups. However, potential impact on pediatric chronic pain has not been assessed at the population level. This study aimed to (1) estimate differences in the US national prevalence of pediatric chronic pain during the first year of the COVID-19 pandemic (2020), relative to one year earlier (2019); (2) determine whether differences in prevalence varied across sociodemographic groups; and (3) explore changes in child, caregiver, and family factors associated with chronic pain prevalence. Using data of children 6 to 17 years from the National Survey of Children's Health 2019 and 2020 (n = 50,518), we compared weighted percentages of sample characteristics by year and conducted a series of directed-acyclic graph-informed survey-weighted Poisson regressions. The estimated national prevalence (95% CI) of pediatric chronic pain was 10.8% (9.9, 11.9%) in 2019, decreasing to 7.6% (6.9, 8.3%) in 2020. Contrary to hypotheses, the adjusted prevalence of chronic pain was 31% lower in 2020 than in 2019 (aPR = 0.69, 95% CI: 0.61, 0.79), adjusting for child age, sex, race or ethnicity, caregiver education, neighborhood park or playground, and census region. The 2019 to 2020 change in chronic pain prevalence was similar by age (P = 0.34), sex (P = 0.94), race or ethnicity (P = 0.41), caregiver education (P = 0.49), neighborhood park or playground (P = 0.22), and census region (P = 0.20). Exploratory analyses identified 3 potential contributors to the unexpected decrease in the national prevalence of pediatric chronic pain: lower prevalence of bullying, more frequent family meals, and higher family resilience.

    View details for DOI 10.1097/j.pain.0000000000003020

    View details for PubMedID 37556380

  • Positive Childhood Experiences and Chronic Pain Among Children and Adolescents in the United States. The journal of pain Pugh, S. J., Murray, C., Groenewald, C. B. 2023; 24 (7): 1193-1202


    Positive childhood experiences (PCEs) are associated with better mental and physical health outcomes and moderate the negative effects of adverse childhood experiences (ACEs). However, knowledge of the associations between PCEs and childhood chronic pain is limited. We conducted a cross-sectional analysis of 2019 to 2020 National Survey of Children's Health (NSCH) to evaluate associations between PCEs and childhood chronic pain. Parents of 47,514 children ages 6 to 17 years old reported on their child's exposure to 7 PCEs and 9 ACEs. Associations between PCEs and chronic pain were evaluated using weighted, multivariate logistic regression analyses adjusted for sociodemographic factors. We found that PCEs had dose-dependent associations with pediatric chronic pain; children exposed to higher numbers of PCEs (5-7 PCEs) had the lowest reported rate of chronic pain (7.1%), while children exposed to 2 or fewer PCEs had the highest rate of chronic pain (14.7%). The adjusted analysis confirmed that children experiencing 5 to 7 PCEs had significantly lower odds of chronic pain relative to children experiencing 0 to 2 PCEs (adjusted odds ratio (aOR): .47, 95% confidence interval (CI): .39-.61, P < .0001). PCEs moderated associations between ACEs and chronic pain: among children reporting 2 or more ACEs, those reporting 5 to 7 PCEs were significantly less likely to report chronic pain as compared to children only reporting 0 to 2 PCEs (aOR: .64, 95%CI: .45-.89, P=.009). In conclusion, children with greater PCEs exposure had lower prevalence rates of chronic pain. Furthermore, PCEs was associated with reduced prevalence of chronic pain among children exposed to ACEs. PERSPECTIVE: This article estimates associations between survey-measured PCEs and pediatric chronic pain among children in the United States. Promoting PCEs could improve pediatric pain outcomes.

    View details for DOI 10.1016/j.jpain.2023.02.001

    View details for PubMedID 36775002

  • We need to talk: The urgent conversation on chronic pain, mental health, prescribing patterns and the opioid crisis JOURNAL OF PSYCHOPHARMACOLOGY Battaglia, M., Groenewald, C. B., Campbell, F., Scaini, S., De Koninck, Y., Stinson, J., Quinn, P. D. 2023: 437-448


    The opioid crisis' pathways from first exposure onwards to eventual illnesses and fatalities are multiple, intertwined and difficult to dissect. Here, we offer a multidisciplinary appraisal of the relationships among mental health, chronic pain, prescribing patterns worldwide and the opioid crisis. Because the opioid crisis' toll is especially harsh on young people, emphasis is given on data regarding the younger strata of the population. Because analgesic opioid prescription constitute a recognised entry point towards misuse, opioid use disorder, and ultimately overdose, prescribing patterns across different countries are examined as a modifiable hazard factor along these pathways of risk. Psychiatrists are called to play a more compelling role in this urgent conversation, as they are uniquely placed to provide synthesis and lead action among the different fields of knowledge and care that lie at the crossroads of the opioid crisis. Psychiatrists are also ideally positioned to gauge and disseminate the foundations for diagnosis and clinical management of mental conditions associated with chronic pain, including the identification of hazardous and protective factors. It is our hope to spark more interdisciplinary exchanges and encourage psychiatrists worldwide to become leaders in an urgent conversation with interlocutors from the clinical and basic sciences, policy makers and stakeholders including clients and their families.

    View details for DOI 10.1177/02698811221144635

    View details for Web of Science ID 000936387200001

    View details for PubMedID 37171242

  • Household Food Insufficiency and Chronic Pain among Children in the US: A National Study CHILDREN-BASEL Tham, S., Law, E. F., Palermo, T. M., Kapos, F. P., Mendoza, J. A., Groenewald, C. B. 2023; 10 (2)


    This study aimed to determine the prevalence of pediatric chronic pain by household food sufficiency status and examine whether food insufficiency would be associated with greater risk for chronic pain. We analyzed data from the 2019-2020 National Survey of Children's Health of 48,410 children (6-17 years) in the United States. Across the sample, 26.1% (95% CI: 25.2-27.0) experienced mild food insufficiency and 5.1% (95% CI: 4.6-5.7) moderate/severe food insufficiency. The prevalence of chronic pain was higher among children with mild (13.7%) and moderate/severe food insufficiency (20.6%) relative to children in food-sufficient households (6.7%, p < 0.001). After adjusting for a priori covariates (individual: age, sex, race/ethnicity, anxiety, depression, other health conditions, adverse childhood events; household: poverty, parent education, physical and mental health; community: region of residence), multivariable logistic regression revealed that children with mild food insufficiency had 1.6 times greater odds of having chronic pain (95% CI: 1.4-1.9, p < 0.0001) and those with moderate/severe food insufficiency, 1.9 higher odds (95% CI: 1.4-2.7, p < 0.0001) relative to food-sufficient children. The dose-response relationship between food insufficiency and childhood chronic pain highlights the importance of further research to identify underlying mechanisms and evaluate the impact of food insufficiency on the onset and persistence of chronic pain across the lifespan.

    View details for DOI 10.3390/children10020185

    View details for Web of Science ID 000938866400001

    View details for PubMedID 36832314

    View details for PubMedCentralID PMC9954897

  • Racial and ethnic differences in pediatric surgery utilization in the United States: A nationally representative cross-sectional analysis JOURNAL OF PEDIATRIC SURGERY Groenewald, C. B., Lee, H. H., Jimenez, N., Ehie, O., Rabbitts, J. A. 2022; 57 (8): 1584-1591


    Children of minority background have reduced access to surgery. This study assessed for racial/ethnic differences in surgical utilization by location.We conducted a cross-sectional analysis of U.S. children (0-17 years of age) participating in the nationally representative Medical Expenditure Panel Survey (MEPS, 2015-2018). Race/ethnicity was the variable of interest. The primary outcome variables were prevalence rates of surgery defined by location of surgical procedure (inpatient, emergency department, hospital outpatient, and office). Covariates included contextual factors that may influence access to and need for healthcare services, including age, sex, insurance status, residential geographic status, usual source of care, and parental reports of child's physical and mental health. We employed multivariate logistic regression models to assess the relationship between outcomes and race/ethnicity.The study population included 31,024 children with an overall surgical rate of 4.8%. Adjusted odds of surgery in an ambulatory location were lower for all racial/ethnic minority groups compared to non-Hispanic White counterparts (non-Hispanic Black aOR = 0.3, 95% CI: 0.2-0.5; Hispanic aOR = 0.4, 95% CI: 0.3-0.6; non-Hispanic Asian aOR = 0.2, 95% CI 0.0-0.5 for hospital outpatient surgery; for office-based setting, non-Hispanic Black aOR = 0.4, 95% CI 0.3-0.6; Hispanic aOR = 0.5, 95% CI: 0.4-0.7; non-Hispanic Asian aOR = 0.4; 95% CI 0.3-0.7). No racial/ethnic differences were observed for surgical procedures in inpatient or emergency department locations.Staggering differences exist in pediatric surgery utilization patterns by racial/ethnic background, even after adjusting for important contextual factors (income, insurance, health status). Our findings in a nationally representative dataset may suggest systemic barriers related to racial/ethnic background for the pediatric surgical population.

    View details for DOI 10.1016/j.jpedsurg.2021.10.011

    View details for Web of Science ID 000853223000024

    View details for PubMedID 34742576

    View details for PubMedCentralID PMC9023599

  • Prevalence of Pain Management Techniques Among Adults With Chronic Pain in the United States, 2019 JAMA NETWORK OPEN Groenewald, C. B., Murray, C. B., Battaglia, M., Scaini, M., Quinn, P. D. 2022; 5 (2): e2146697


    This cross-sectional study estimates the prevalence of opioid and nonopioid pain management techniques used by US adults with chronic pain.

    View details for DOI 10.1001/jamanetworkopen.2021.46697

    View details for Web of Science ID 000754036700003

    View details for PubMedID 35129599

    View details for PubMedCentralID PMC8822381

  • Can Use of Default Dispensing Quantities in Electronic Medical Record Lower Opioid Prescribing? Pediatric emergency care Chua, W. J., Groenewald, C. B., Varakitsomboon, S., Harris, J., Faino, A. V., Quan, L., Walco, G. A., Sousa, T. C. 2022; 38 (2): e600-e604


    Leftover opioids can contribute to misuse and abuse. Recommended dosing quantities in the electronic medical record can guide prescribing patterns. We hypothesized that decreasing the default from 30 doses to 12 doses would decrease the overall number of opioids prescribed without increasing second opioid prescriptions or additional health utilization.We performed a single-center retrospective study of children with forearm and elbow fractures who presented to the emergency department for evaluation and subsequent orthopedic follow-up between January 15, and September 19, 2017. The default dispensing quantity was decreased on June 1, 2016 from 30 doses to 12 doses. Patients were categorized to preintervention and postintervention groups. We compared the number of opioids prescribed, second opioid prescriptions, emergency department visits, and pain-related telephone calls and orthopedic visits with χ2 and logistic regression analyses.There were 1107 patients included. Rates of opioid prescribing were similar preintervention and postintervention (61% vs 56%, P = 0.13). After the change to the default quantity, the median number of doses decreased from 18 to 12 doses, with opioid prescriptions of 30 or more doses dropping from 35% to 11%. No significant association was found between preintervention versus postintervention, opioid prescription at discharge, and having 1 or more pain-related or unexpected follow-up visits.Lowering the default dispensing quantity of opioids in the electronic medical record decreases the number of opioids prescribed without increasing second prescriptions or additional health care utilization. These findings suggest that a further reduction in the number of opioids prescribed for upper-extremity fractures may be possible.

    View details for DOI 10.1097/PEC.0000000000002411

    View details for PubMedID 35100763

    View details for PubMedCentralID PMC9269031

  • Healthcare utilization and costs among pediatric patients with chronic postsurgical pain after major musculoskeletal surgery PEDIATRIC ANESTHESIA Ellyson, A. M., Powelson, E. B., Groenewald, C. B., Rabbitts, J. A. 2022; 32 (4): 577-578

    View details for DOI 10.1111/pan.14402

    View details for Web of Science ID 000761745300001

    View details for PubMedID 35075715

    View details for PubMedCentralID PMC9269163

  • Associations between insufficient sleep and prescription opioid misuse among high school students in the United States. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Groenewald, C. B., Rabbitts, J. A., Tham, S. W., Law, E. F., Palermo, T. M. 2021; 17 (11): 2205-2214


    The aim of this study was to estimate the association between insufficient sleep and prescription opioid misuse among US high school students.Participants were 6,884 high school students who self-reported on sleep duration and prescription opioid misuse in the 2019 Youth Risk Behavior Survey. Sleep duration was categorized by the Youth Risk Behavior Survey according to the American Academy of Sleep Medicine guidelines as follows: recommended sleep duration (8-9 hours) vs insufficient sleep (< 8 hours). Participants also reported whether they had any prescription opioid misuse during their lifetime and whether they had prescription opioid misuse within the past 30 days.Most (79.4%) participants reported sleeping less than 8 hours per night. Among all youth, 12.9% reported lifetime prescription opioid misuse and 6.2% reported current prescription opioid misuse. Prevalence of both lifetime and current opioid medication misuse was higher among those also reporting insufficient sleep compared to those reporting recommended sleep duration (14.3% vs 7.7%, P < .0001 for lifetime misuse and 6.6% vs 4.3%, P = .0091 for current misuse). In multivariate models, insufficient sleep was associated with an increased odds of lifetime prescription opioid misuse (adjusted odds ratios = 1.4; 95% confidence interval, 1.1-1.2; P = .006); however, we did not find an association between sleep duration and current prescription opioid misuse in multivariate analysis.Sleep duration is associated with lifetime opioid misuse among US youth. Longitudinal studies are needed to test whether causal relationships exist, and to understand biobehavioral mechanisms that underlie associations between sleep deficiency and opioid misuse in adolescents.Groenewald CB, Rabbitts JA, Tham SW, Law EF, Palermo TM. Associations between insufficient sleep and prescription opioid misuse among high school students in the United States. J Clin Sleep Med. 2021;17(11):2205-2214.

    View details for DOI 10.5664/jcsm.9418

    View details for PubMedID 34019477

    View details for PubMedCentralID PMC8636372

  • Prescription Opioid Misuse and Sports-Related Concussion Among High School Students in the United States JOURNAL OF HEAD TRAUMA REHABILITATION Tham, S., Palermo, T. M., Chrisman, S. D., Groenewald, C. B. 2021; 36 (5): 338-344


    Concussion is highly prevalent in adolescents and associated with a higher risk of substance use. With the rising use of opioids among adolescents, one form of substance use of concern is the misuse of prescription opioids. This study aimed to examine the association between a history of sports-related concussion in the past year and current prescription opioid misuse among high school students in the United States.Secondary data analysis from the 2019 Youth Risk Behavior Survey.Nationally representative sample of high school students (n = 7314).Cross-sectional study.Participants were asked whether they experienced any concussions related to sports or being physically active during the past 12 months and whether they had any prescription opioid misuse within the past 30 days.Among this cohort, 14.0% reported sustaining a concussion in the past 12 months and 6% reported current prescription opioid misuse. The prevalence of prescription opioid misuse was higher among those with a history of concussion (9.9%) than among those without concussion (5.5%, P = .002). Controlling for covariates (sex, race/ethnicity, other substance use, depressive symptoms), the odds of prescription opioid misuse was 1.5 times higher for adolescents with concussion than those without (adjusted odds ratios [aOR] = 1.5; 95% CI, 1.0-2.3; P = .029).Concussion was associated with prescription opioid misuse among the US youth, even after accounting for depressive symptoms and other substance use. Longitudinal studies are needed to test causal relationships and understand biobehavioral mechanisms that underlie associations between concussion and opioid misuse in adolescents.

    View details for DOI 10.1097/HTR.0000000000000706

    View details for Web of Science ID 000692444300010

    View details for PubMedID 34489384

    View details for PubMedCentralID PMC8428243

  • Training the Trainers in Ultrasound-guided Access to Improve Peripheral Intravenous Catheter Placement among Children Presenting for Anesthesia PEDIATRIC QUALITY & SAFETY O'Reilly-Shah, V. N., Franz, A., Groenewald, C. B., Collins, M., Patak, L. S. 2021; 6 (3): e406


    Factors predicting difficult peripheral intravenous (PIV) catheter placement in children are known. Ultrasound guidance can decrease the number of attempts required for difficult PIV placement. However, the uptake of this technique among attending anesthesiologists at our institution remained low. This study aimed to reduce the incidence of PIV placement requiring greater than 3 attempts and reduce time to PIV placement by providing training in ultrasound guidance.We implemented an evidence-based difficult IV algorithm and ultrasound-guided PIV placement training for attending pediatric anesthesiologists at a tertiary academic pediatric institution. The algorithm outlined risk factors for difficult IV access, established a goal of 3 or fewer attempts, and recommended early ultrasound use after 1 unanticipated attempt and the first attempt for anticipated difficult IV. Group sessions, including instruction and simulated practice, preceded a period of individual training in the operating room using a punch card to monitor each trainee's progress while also serving to motivate continued engagement.We performed a cross-sectional analysis of consecutive cases from December 1, 2015, to September 30, 2019, comparing a 22-month baseline period (n = 12,581) with the training period (n = 6,725) and the following year (n = 6,557). Cases requiring more than 3 attempts decreased from 4.0% to 2.7% overall and from 10% to 6.2% among patients 24 months or less of age. The time required to establish PIV access was unchanged. Factors associated with increased attempts were identified.Implementing a difficult IV algorithm and training among attending pediatric anesthesiologists in ultrasound-guided PIV placement reduced attempts but not the time required to establish PIV access.

    View details for DOI 10.1097/pq9.0000000000000406

    View details for Web of Science ID 000714179400009

    View details for PubMedID 33977194

    View details for PubMedCentralID PMC8104256

  • Associations between adolescent sleep deficiency and prescription opioid misuse in adulthood. Sleep Groenewald, C. B., Law, E. F., Rabbitts, J. A., Palermo, T. M. 2021; 44 (3)


    The main aim of this study was to estimate the association between sleep deficiency in adolescence and subsequent prescription opioid misuse in adulthood using United States nationally representative longitudinal data.Self-reported data captured in the National Longitudinal Study of Adolescent to Adult Health at baseline (Wave 1; mean age = 16 years) and 12 year follow-up (Wave 4; mean age = 29 years). Participants (n = 12,213) reported on four measures of sleep during adolescence (Wave 1) and on lifetime prescription opioid misuse during adulthood (Wave 4). Associations between adolescent sleep and adult opioid misuse were estimated using multivariate logistic regression analysis controlling for sociodemographics, chronic pain, mental health, childhood adverse events, and a history of substance use.During adolescence, 59.2% of participants reported sleep deficiency. Prospectively, adolescents reporting not getting enough sleep, chronic unrestful sleep, and insomnia were associated with an increased risk for prescription opioid misuse (adjusted odds ratios [OR] = 1.2, p < 0.005 for all three variables). Short sleep duration was not associated with opioid misuse.This is the first study to longitudinally link sleep deficiency as an independent risk factor for the development of prescription opioid misuse. Sleep deficiency could be a driver of the opioid crisis affecting young people in the United States. Future studies should determine whether early and targeted sleep interventions may decrease risk for opioid misuse in high-risk patients prescribed opioids for pain.

    View details for DOI 10.1093/sleep/zsaa201

    View details for PubMedID 32978633

    View details for PubMedCentralID PMC7953216

  • The Role of Sleep in the Transition from Acute to Chronic Musculoskeletal Pain in Youth-A Narrative Review CHILDREN-BASEL Andreucci, A., Groenewald, C. B., Rathleff, M., Palermo, T. M. 2021; 8 (3)


    Musculoskeletal pain is common in the general pediatric population and is a challenge to youth, their parents, and society. The majority of children experiencing musculoskeletal pain will recover; however, a small subgroup of youth develops chronic pain. There is limited understanding of the factors that affect the transition from acute to chronic pain in youth. This review introduces sleep deficiency in the acute to chronic pain transition, exploring the potential mediational or mechanistic role and pathways of sleep in this process, including the interaction with sensory, psychological, and social components of pain and highlighting new avenues for treatment. Biological mechanisms include the increased production of inflammatory mediators and the effect on the hypothalamus-pituitary-adrenal (HPA) axis and on the dopaminergic signaling. Psychological and social components include the effect of sleep on the emotional-affective and behavioral components of pain, the negative impact on daily and social activities and coping strategies and on the reward system, increased pain catastrophizing, fear of pain, pain-related anxiety, hypervigilance, and social isolation. Future longitudinal studies are needed to elucidate these mechanistic pathways of the effect of sleep on the transition from acute to chronic pain, which may lead to the development of new treatment targets to prevent this transition.

    View details for DOI 10.3390/children8030241

    View details for Web of Science ID 000633466900001

    View details for PubMedID 33804741

    View details for PubMedCentralID PMC8003935

  • Association of Headache With School Functioning Among Children and Adolescents in the United States JAMA PEDIATRICS Turner, S. B., Szperka, C. L., Hershey, A. D., Law, E. F., Palermo, T. M., Groenewald, C. B. 2021; 175 (5): 522-524


    This cross-sectional study examines the association between headache in children and school functioning in the US.

    View details for DOI 10.1001/jamapediatrics.2020.5680

    View details for Web of Science ID 000621530600012

    View details for PubMedID 33523093

    View details for PubMedCentralID PMC7851753

  • Subacute pain trajectories following major musculoskeletal surgery in adolescents: A pilot study CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR Rabbitts, J. A., Groenewald, C. B., Zhou, C. 2020; 4 (4): 3-12


    Adolescents who undergo major surgery experience high rates of disabling acute and chronic postsurgical pain (CPSP). However, little is known about the subacute period when acute to chronic pain transition occurs.Examine feasibility of electronic daily monitoring of pain and opioid use in adolescents during the first 30-days at home following major surgery, and identify target features of subacute pain curves associated with CPSP at 4 months.25 youth (10-18 years) undergoing major musculoskeletal surgery reported daily pain severity, interference, and opioid use on the Brief Pain Inventory, each evening for 30 days after hospital discharge, to form short time series trajectories. At 4 months, youth reported on pain intensity and health-related quality of life. Characteristics of subacute pain severity and interference curves were compared by 4-month CPSP status.At 4 months, 20.8% of youth met criteria for CPSP. During the 30-day monitoring period, youth who went on to develop CPSP reported high pain severity on 45.9% of days as compared to 2.9% of days in youth who recovered (P=0.005), and high pain interference on 49.4% of days vs. 9.7% in youth who recovered (P=0.01). Pain variability and rate of change were not significantly associated with CPSP in our pilot sample.We found it feasible to collect daily pain data in youth recovering at home after major surgery. Pilot findings suggest that daily electronic monitoring may identify early recovery problems at home after surgery. Larger studies are needed to validate subacute pain trajectory features to identify risk for CPSP.

    View details for DOI 10.1080/24740527.2020.1765692

    View details for Web of Science ID 000605584200002

    View details for PubMedID 33415314

    View details for PubMedCentralID PMC7787390

  • Impaired School Functioning in Children With Chronic Pain: A National Perspective. The Clinical journal of pain Groenewald, C. B., Tham, S. W., Palermo, T. M. 2020; 36 (9): 693-699


    The purpose of this study was to determine the association between presence of chronic pain and school functioning among school-aged children (6 to 17 y) using the most recent United States national data.Secondary data analyses of the 2016-2017 National Survey of Children's Health. Parents (n=48,254) reported on whether their child had chronic pain over the past 12 months. Parents also reported on school functioning including (1) engagement with school, (2) number of school days missed, (3) problems at school, (4) repeating a grade, and (5) diagnosis of a learning disability. Children with chronic pain were compared with children without chronic pain using multivariate logistic regression models. We also stratified analysis according to age and sex.In multivariate analyses, children with pain were more likely to have low school engagement (adjusted odds ratio [OR]: 1.4, 95% confidence interval [CI]: 1.0-1.9), be chronically absent (OR: 4.2, 95% CI: 3.0-5.8), have school-related problems (OR: 1.9, 95% CI: 1.5-2.3), repeat a grade (OR: 1.4, 95% CI: 1.0-2.0), and be diagnosed with a learning disability (OR: 1.6, 95% CI: 1.1-2.5). In stratified analyses, associations between chronic pain and school measures were strongest among adolescents (15 to 17 y of age) and males.This study extends evidence linking chronic pain status to poorer school functioning in a large, national sample. Poor school functioning is a pressing public concern affecting children with chronic pain. Health care providers, educators, policymakers, and families should work together to ensure that needs are met for this vulnerable population.

    View details for DOI 10.1097/AJP.0000000000000850

    View details for PubMedID 32487871

    View details for PubMedCentralID PMC7429324

  • Adverse childhood experiences and chronic pain among children and adolescents in the United States PAIN REPORTS Groenewald, C. B., Murray, C. B., Palermo, T. M. 2020; 5 (5): e839


    To evaluate the association between adverse childhood experiences (ACEs) and chronic pain during childhood and adolescence.Cross-sectional analysis of the 2016-2017 National Survey of Children's Health, including 48,567 child participants of 6 to 17 years of age. Parents of children reported on 9 ACEs. Chronic pain was defined as parents reporting that their children had "frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain during the past 12 months." Multivariate logistic regression analysis adjusted for sociodemographic and health-related factors.In this nationally representative sample, 49.8% of children were exposed to one or more ACEs during their lifetime. Children with exposure to 1 or more ACEs had higher rates of chronic pain (8.7%) as compared to those with no reported ACEs (4.8%). In multivariate analysis, children with ACEs had increased odds for chronic pain (adjusted odds ratio [aOR]: 1.6, 95% confidence interval [CI]: 1.3-2.2, for 0 vs 1 ACE and aOR: 2.7, 95% CI: 2.1-3.4 for 0 vs 4+ ACEs). The strongest associations of individually measured ACEs with chronic pain included financial instability (aOR: 1.9, 95% CI: 1.6-2.2), living with a mentally ill adult (aOR: 1.8, 95% CI: 1.5-2.2), and having experienced discrimination based on race (aOR: 1.7, 95% CI: 1.3-2.2).Children and adolescents with ACEs had increased risk for chronic pain, and this association increased in a dose-dependent fashion.

    View details for DOI 10.1097/PR9.0000000000000839

    View details for Web of Science ID 000693789300008

    View details for PubMedID 32903388

    View details for PubMedCentralID PMC7431222

  • Epidemiology of Pediatric Surgery in the United States PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B. 2020; 30 (10): 1083-1090


    The epidemiology of pediatric surgery in the United States and whether disparities in access to surgical care exist on a national level remain inadequately described.We determined rates of surgical intervention and associations with sociodemographic factors among children 0-17 years of age in the United States.Analysis of the 2005-2018 National Health Interview Survey samples included 155,064 children. Parents reported on whether their child had a surgery or surgical procedure either as an inpatient or outpatient over the past 12 months. Multivariate logistic regression models, adjusted for age, sex, race and ethnicity, income, language, parent education, region, having a usual source of care, and comorbid conditions, examined odds ratios for sociodemographic factors associated with surgery, analyzing the most recent data (2016-2018; 25 544 children).In the most recent data, 4.7% of children had surgical intervention each year, with an average of 3.9 million surgeries performed annually. Rates of surgery were stable between 2005 and 2018. Minority children had lower adjusted odds (aOR) of surgical intervention as compared to white, non-Hispanic children (aOR = 0.6, 95%CI = 0.5-0.8 for black children, and aOR = 0.7, 95%CI = 0.5-0.9 for Hispanic children). Other sociodemographic factors associated with a lower adjusted odd of surgical intervention included uninsured status (aOR = 0.5; 95%CI = 0.3-0.9), and primary language other than English (aOR = 0.5; 95%CI 0.3-0.9). Income was not associated with surgical intervention.On average, 3.9 million surgeries are performed on children 0-17 years of age in the United States each year. Significant disparities exist in surgical care for children, with black and Hispanic children having lower rates of surgery over and above contribution of other disparity domains. These findings in a nationally representative sample highlight the need for national policies to eliminate disparity of care received by minority children.

    View details for DOI 10.1111/pan.13993

    View details for Web of Science ID 000563639400001

    View details for PubMedID 32777147

    View details for PubMedCentralID PMC7891905

  • Consideration of Adolescent Pain in Responses to the Opioid Crisis. JAMA psychiatry Battaglia, M., Quinn, P. D., Groenewald, C. B. 2020

    View details for DOI 10.1001/jamapsychiatry.2020.1694

    View details for PubMedID 32936227

    View details for PubMedCentralID PMC7891903

  • Correlates and motivations of prescription opioid use among adolescents 12 to 17 years of age in the United States. Pain Groenewald, C. B., Patel, K. V., Rabbitts, J. A., Palermo, T. M. 2020; 161 (4): 742-748


    Despite significant efforts, the opioid crisis remains a pressing health concern affecting adolescents. The primary aim of this study was to describe recent sociodemographic shifts in the opioid epidemic. We examined whether rates of opioid use, including opioid misuse and opioid use disorder among 12 to 17 year olds in the United States, differ according to sociodemographic factors, physical and mental health, and substance use characteristics using data from the 2015 and 2016 National Survey on Drug Use and Health. We also examined motivations for opioid misuse. The study included 27,857 participants. Black, non-Hispanic adolescents were more likely to both use and misuse opioids as compared to white, non-Hispanic adolescents, a clear difference from previous studies. The main motivation for misuse by adolescents was relief of physical pain (50%, 95% confidence interval 46%-54%). Adolescents who reported pain relief as the major reason for misuse had increased odds of substance use as compared to adolescents who did not report any opioid misuse. However, odds for substance use was greatest among adolescents who reported reasons other than pain relief for opioid misuse. National Survey on Drug Use and Health self-report data suggest recent shifts in opioid misuse with minority adolescents appearing to be at increased risk of opioid misuse compared with white adolescents. Relief of physical pain is the most common motivation for opioid misuse.

    View details for DOI 10.1097/j.pain.0000000000001775

    View details for PubMedID 31815917

    View details for PubMedCentralID PMC7085424

  • Long-term impact of adolescent chronic pain on young adult educational, vocational, and social outcomes PAIN Murray, C. B., Groenewald, C. B., de la Vega, R., Palermo, T. M. 2020; 161 (2): 439-445


    Despite evidence of broad impact on daily functioning in adolescence, little is known regarding the life course effects of childhood chronic pain. This is the first nationally representative study to characterize the disruptive impact of chronic pain in adolescence on key educational, vocational, and social outcomes in young adulthood (12 years later). Data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) were used, including 3174 youth with chronic pain and 11,610 without chronic pain. Multivariate regression analyses controlling for sociodemographic factors and adolescent depression found that chronic pain in adolescence was associated with long-term risk of a constellation of impairments indicative of socioeconomic disparities. Specifically, adolescent chronic pain was subsequently associated with reduced educational attainment (eg, lower odds of attaining a high school diploma and bachelor's degree), poor vocational functioning (eg, lower odds of receiving employer-provided benefits and higher odds of receiving public aid), and social impairments (eg, early parenthood, lower self-reported romantic relationship quality) in young adulthood. These findings provide a window into the future of adolescents with chronic pain, contributing to the limited knowledge base of the scope of adverse long-term outcomes during the transition to adulthood. However, several questions remain. Increased research attention is needed to understand the life course impact of pediatric chronic pain, including early risk factors and underlying mechanisms that drive adverse outcomes as they unfold across the lifespan.

    View details for DOI 10.1097/j.pain.0000000000001732

    View details for Web of Science ID 000524504200021

    View details for PubMedID 31651579

    View details for PubMedCentralID PMC7001863

  • Associations Between Opioid Prescribing Patterns and Overdose Among Privately Insured Adolescents PEDIATRICS Groenewald, C. B., Zhou, C., Palermo, T. M., Van Cleve, W. C. 2019; 144 (5)


    Little is known about the risk for overdose after opioid prescription. We assessed associations between the type of opioid, quantity dispensed, daily dose, and risk for overdose among adolescents who were previously opioid naive.Retrospective analysis of 1 146 412 privately insured adolescents ages 11 to 17 years in the United States captured in the Truven MarketScan commercial claims data set from January 2007 to September 2015. Opioid overdose was defined as any emergency department visit, inpatient hospitalization, or outpatient health care visit during which opioid overdose was diagnosed.Among our cohort, 725 participants (0.06%) experienced an opioid overdose, and the overall rate of overdose events was 28 events per 100 000 observed patient-years. Receiving ≥30 opioid tablets was associated with a 35% increased risk for overdose compared to receiving ≤18 tablets (hazard ratio [HR] = 1.35; 95% confidence interval: 1.05-1.73; P = .02). Daily prescribed opioid dose was not independently associated with an increased risk for overdose. Tramadol exposure was associated with a 2.67-fold increased risk for opioid overdose compared to receiving oxycodone (adjusted HR = 2.67; 95% confidence interval: 1.90-3.75; P < .0001). Adolescents with preexisting mental health conditions demonstrated increased risk for overdose, with HRs ranging from 1.65 (anxiety) to 3.09 (substance use disorders).One of 1600 (0.06%) previously opioid-naive adolescents who received a prescription for opioids experienced an opioid overdose a median of 1.75 years later that resulted in medical care. Preexisting mental health conditions, use of tramadol, and higher number of dispensed tablets (>30 vs <18) were associated with an increased risk of opioid overdose.

    View details for DOI 10.1542/peds.2018-4070

    View details for Web of Science ID 000494681400016

    View details for PubMedID 31575622

    View details for PubMedCentralID PMC6856776

  • Patterns and predictors of difficult intravenous access among children presenting for procedures requiring anesthesia at a tertiary academic medical center PEDIATRIC ANESTHESIA Patak, L. S., Stroschein, K. M., Risley, R., Collins, M., Groenewald, C. B. 2019; 29 (10): 1068-1070

    View details for DOI 10.1111/pan.13734

    View details for Web of Science ID 000490801000016

    View details for PubMedID 31602736

    View details for PubMedCentralID PMC7137765

  • Economic Impact of Headache and Psychiatric Comorbidities on Healthcare Expenditures Among Children in the United States: A Retrospective Cross-Sectional Study HEADACHE Law, E. F., Palermo, T. M., Zhou, C., Groenewald, C. B. 2019; 59 (9): 1504-1515


    To examine the annual healthcare expenditures associated with childhood headache in the United States, and to evaluate whether psychiatric comorbidities increase the impact of headache on expenditures.Headache is prevalent in childhood and co-occurs with anxiety disorders, depressive disorders, and attention deficit/hyperactivity disorder (ADHD), which may increase cost of illness.We conducted a secondary data analysis using a nationally representative sample of 34,633 children ages 2-17 from the 2012-2015 Medical Expenditure Panel Surveys (MEPS), of which 779 (weighted 2.6%) were identified as having headache based on health service use associated with headache. Using a comprehensive cost-of-illness approach, we assessed the incremental expenditures associated with headache and determined excess expenditures associated with psychiatric comorbidities using standard adjusted 2-part expenditure models.Annual total healthcare expenditures were estimated to be 24.3% higher, 95% CI [1,55], in our headache group ($3036, 95% CI [2374,3699] vs $2350, 95% CI [2140,2559]). Total national expenditures associated with pediatric headache in the United States were estimated at $1.1 billion annually, 95% CI [.04, 2.2 billion]. Depression and ADHD were associated with higher incremental expenditures for the headache group (depression: $1815, 95% CI[676,2953] vs $1409, 95% CI[697,2112]; ADHD: $4742, 95% CI[1659,7825] vs $2935, 95% CI[1977,3894]); however, interactions between psychiatric comorbidities and headache did not reach statistical significance.Youth with headache exert a considerable economic burden on families, healthcare systems, and society. Due to the limitations in methods used to classify youth with headache in MEPS, our findings may underestimate the true prevalence and cost of pediatric headache in the United States. Further research with larger sample sizes is needed to understand the impact of psychiatric comorbidities on healthcare expenditures in this population.

    View details for DOI 10.1111/head.13639

    View details for Web of Science ID 000492205300007

    View details for PubMedID 31520418

    View details for PubMedCentralID PMC6818708

  • Opioid-prescribing Patterns for Pediatric Patients in the United States. The Clinical journal of pain Groenewald, C. B. 2019; 35 (6): 515-520


    The opioid crisis in America affects both adults and children. However, knowledge about the epidemiology of the opioid crisis, opioid prescribing patterns, and the link between opioid prescribing and problematic opioid behaviors remain limited. Thus, children are often excluded from health care policies and guidelines aimed at curbing the opioid crises. The primary aim of this topical review is to provide a brief overview of the opioid crises affecting children, followed by a synopsis of recent research on opioid prescribing patterns and data on the links between legitimate opioid use and risk for problematic opioid use behaviors.This is a narrative review.Opioid misuse is a public health crisis facing children and adolescents in the United States and serves as a key antecedent for other problematic opioid behaviors, including opioid use disorder, heroin use, and opioid overdose. Furthermore, the United States experienced a significant increase in opioid prescribing to children and adolescents as compared with prescribing rates before the year 2000. Yet, data on the associations between opioid prescribing patterns and risk for problematic opioid use remains limited.There exist an urgent need to identify adolescents at increased risk for problematic opioid use behaviors following a receipt of medically prescribed opioids. The article closes with some general guidelines that providers may follow to reduce the risk of opioids in pediatric patients.

    View details for DOI 10.1097/AJP.0000000000000707

    View details for PubMedID 30985396

    View details for PubMedCentralID PMC6782052

  • School Absence Associated With Childhood Pain in the United States. The Clinical journal of pain Groenewald, C. B., Giles, M., Palermo, T. M. 2019; 35 (6): 525-531


    The objective of this study was to estimate the national burden of school absenteeism associated with pain among 6 to 17-year-old children in the United States.Data were analyzed from a large, nationally representative sample from the 2012 National Health Interview Survey. Associations between pain and school absence were analyzed using multivariate negative binomial models controlling for sociodemographic and clinical characteristics.The sample contained 8641 participants, of whom 30.3% reported pain over the preceding 12 months. Mean number of parent-reported school days missed across the entire sample was 3 per child; however pain was associated with an additional 1.5 reported missed school days per child. Furthermore, pain was associated with higher rates of chronic absenteeism (missing >15 d of school): 6.1% of children with pain was chronically absent as compared with 1.3% of children without pain. Extrapolated to the nation, childhood pain in the United States was associated with 22.2 million additional days of missed school, whereas childhood asthma, in comparison, was associated with 8 million additional days of school missed.Associations between pain and school absenteeism highlight the need for interventions aimed at improving school attendance among children with pain.

    View details for DOI 10.1097/AJP.0000000000000701

    View details for PubMedID 30844952

    View details for PubMedCentralID PMC6502652

  • Associations Between Adolescent Chronic Pain and Prescription Opioid Misuse in Adulthood. The journal of pain Groenewald, C. B., Law, E. F., Fisher, E., Beals-Erickson, S. E., Palermo, T. M. 2019; 20 (1): 28-37


    Prescription opioid misuse is a serious public health concern, yet antecedent factors are poorly described. Using data from the National Longitudinal Study of Adolescent to Adult Health (N = 14,784), we examined the longitudinal relationship between a history of adolescent chronic pain and the odds of misusing prescription opioids in adulthood. The primary predictor variable was chronic pain status during adolescence. The primary outcome variables were prescription opioid misuse during early adulthood and adulthood. Multivariate models controlled for known risk factors of opioid misuse, including sociodemographics (sex, race, and ethnicity), adolescent mental health symptoms (anxiety, depression), adolescent self-reported physical health status, adolescent substance use/abuse, childhood trauma, and adult legitimate opioid use. We found that adults with a history of adolescent chronic pain were more likely to misuse opioids than those without history of chronic pain, even after controlling for other known risk factors. Further, we found that among individuals with history of adolescent chronic pain that race (white), other substance use, and exposure to trauma were risk factors for later opioid misuse. Longitudinal associations between adolescent chronic pain and subsequent adult prescription opioid misuse highlight the need for early targeted screening and prevention efforts that may reduce later opioid misuse. Perspective: Using a large, nationally representative sample, we found that chronic pain during adolescence was an independent risk factor for opioid misuse in adulthood, over and above other known risk factors. Furthermore, among those individuals with adolescent chronic pain, substance use, exposure to trauma, and race were associated with opioid misuse.

    View details for DOI 10.1016/j.jpain.2018.07.007

    View details for PubMedID 30098405

    View details for PubMedCentralID PMC6309740

  • Racial differences in opioid prescribing for children in the United States. Pain Groenewald, C. B., Rabbitts, J. A., Hansen, E. E., Palermo, T. M. 2018; 159 (10): 2050-2057


    Racial differences exist in analgesic prescribing for children during emergency department and ambulatory surgery visits in the United States; however, it is unknown whether this is true in the outpatient setting. We examined racial and ethnic differences in outpatient analgesic prescribing using nationally representative data from 113,929 children from the Medical Expenditure Panel Survey. We also examined whether patient-provider race and ethnic concordance was associated with opioid prescription. White children were more commonly prescribed opioids as compared to minorities (3.0% vs 0.9%-1.7%), except for Native American children who had similar rates of opioid prescription (2.6%) as white children. Minorities were more likely to receive nonopioid analgesics than white children (2.0%-5.7% vs 1.3%). Although most white children had race-concordant providers (93.5%), only 34.3% of black children and 42.7% of Hispanic children had race-concordant providers. Among black children, having a race concordant usual source of care provider was associated with a decreased likelihood of receiving an opioid prescription as compared to having a white usual source of care provider (adjusted odds ratio [95% confidence interval] = 0.51 [0.30-0.87]). For all other racial groups, patient-provider race-concordance was not associated with likelihood of opioid prescription. Racial differences exist in analgesic prescriptions to children at outpatient health care visits in the United States, with white children more likely to receive opioids and minorities more likely to receive nonopioid analgesics. Health care providers' race and ethnicity may play a significant role in extant analgesic differences. Further work should focus on understanding the role of provider race and ethnicity in analgesic differences to children in the United States.

    View details for DOI 10.1097/j.pain.0000000000001290

    View details for PubMedID 29794611

    View details for PubMedCentralID PMC6150822

  • Effect on Health Care Costs for Adolescents Receiving Adjunctive Internet-Delivered Cognitive-Behavioral Therapy: Results of a Randomized Controlled Trial JOURNAL OF PAIN Law, E. F., Groenewald, C. B., Zhou, C., Palermo, T. M. 2018; 19 (8): 910-919


    The economic burden of pediatric chronic pain is high, with an estimated annual cost of $19.5 billion. Little is known about whether psychological treatment for pediatric chronic pain can alter health care utilization for youth. The primary aim of this secondary data analysis was to evaluate the effect of adjunctive internet cognitive-behavioral therapy intervention or adjunctive internet education on health care-related economic costs in a cohort of adolescents with chronic pain recruited from interdisciplinary pain clinics across the United States. For the full sample, health care expenditures significantly decreased from the year before the intervention to the year after the intervention. Results indicated that the rate of change in health care costs over time was not significantly different between the internet cognitive-behavioral therapy intervention and adjunctive internet education groups. Further research is needed to replicate these findings and determine patterns and drivers of health care costs for youth with chronic pain evaluated in interdisciplinary pain clinics and whether psychological treatments can alter these patterns. This trial was registered at (identifier NCT01316471).Health care expenditures significantly decreased in youth with chronic pain from the year before initiating treatment to the following year in both intervention conditions, adjunctive internet cognitive-behavioral therapy and adjunctive internet education. Contrary to our hypothesis, the rate of change in health care costs over time was not significantly different between intervention conditions.

    View details for DOI 10.1016/j.jpain.2018.03.004

    View details for Web of Science ID 000441226800008

    View details for PubMedID 29578090

    View details for PubMedCentralID PMC6066421

  • Chronic pain prevalence and associated factors in adolescents with and without physical disabilities DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY De la Vega, R., Groenewald, C., Bromberg, M. H., Beals-Erickson, S. E., Palermo, T. M. 2018; 60 (6): 596-+


    Adolescents with physical disabilities may have co-occurring chronic pain, but the prevalence and specific associated factors are unknown. The aims of this study were to determine (1) the prevalence of chronic pain in adolescents with physical disabilities and (2) whether known correlates of chronic pain in the general population are also present in young people both with physical disability and with chronic pain relative to peers.We conducted a secondary analysis of cross-sectional nationally representative data from the National Longitudinal Study of Adolescent to Adult Health. Multivariate linear regression analysis was used to identify demographic and psychosocial factors associated with chronic pain.A total of 989 (4.3%) adolescents reported physical disabilities. They had a significantly higher rate of pain (27.2%) compared with able-bodied peers (15.6%, χ2 =86.3550, p<0.001). There was no significant interaction between physical disability status and chronic pain in relation to depressive symptoms, anxiety, or insomnia.Adolescents with physical disabilities experience chronic pain at a significantly higher rate than able-bodied peers, but the comorbidity of physical disability and chronic pain is not related to depression, anxiety, or insomnia. Evaluation of chronic pain and tailored pain interventions need to be developed for this population.Chronic pain and its correlates are important problems for adolescents with physical disabilities. These adolescents present with higher rates of chronic pain than other young people. Chronic pain is associated with increased levels of depressive symptoms, anxiety, and insomnia regardless of disability status.

    View details for DOI 10.1111/dmcn.13705

    View details for Web of Science ID 000431983700020

    View details for PubMedID 29468673

    View details for PubMedCentralID PMC5943137

  • Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group ANESTHESIA AND ANALGESIA Thompson, D. R., Zurakowski, D., Haberkern, C. M., Stricker, P. A., Meier, P. M., Pediat Craniofacial Collaborat Grp 2018; 126 (3): 968-975


    The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry.Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis.Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001).This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

    View details for DOI 10.1213/ANE.0000000000002454

    View details for Web of Science ID 000425343900032

    View details for PubMedID 28922233

  • Combining morphine and ibuprofen does not improve pain control compared with using either drug alone following musculoskeletal injury in children. Evidence-based nursing Groenewald, C. B. 2018; 21 (4): 107

    View details for DOI 10.1136/eb-2018-102918

    View details for PubMedID 30032108

  • Morphine is not superior to ibuprofen for managing children's pain following minor orthopedic surgery. Evidence-based nursing Groenewald, C. B. 2018; 21 (2): 48

    View details for DOI 10.1136/eb-2017-102855

    View details for PubMedID 29514849

  • Complementary and Alternative Medicine Use by Children With Pain in the United States ACADEMIC PEDIATRICS Groenewald, C. B., Beals-Erickson, S. E., Ralston-Wilson, J., Rabbitts, J. A., Palermo, T. M. 2017; 17 (7): 785-793


    Chronic pain is reported by 15% to 25% of children. Growing evidence from clinical samples suggests that complementary and alternative medicine (CAM) therapies are desired by families and may benefit some children with pain conditions. The objective of this study was to provide estimates of CAM use by children with pain in the United States.We analyzed data from the 2012 National Health Interview Survey (NHIS) to estimate patterns, predictors, and perceived benefits of CAM use among children 4 to 17 years of age with and without painful conditions in the United States. We used chi-square tests to compare the prevalence rates of CAM use among children with pain to CAM use among children without pain. Multivariable logistic regression was used to examine factors associated with CAM use within the group of children with pain conditions.Parents reported that 26.6% of children had pain conditions (eg, headache, abdominal, musculoskeletal pain) in the past year; of these children, 21.3% used CAM. In contrast, only 8.1% of children without pain conditions used CAM (χ2, P < .001). CAM use among children with pain was associated with female sex (adjusted odds ratio [aOR] = 1.49, P = .005), higher income (aOR = 1.61, P = .027), and presence of 4+ comorbidities (aOR = 2.01, P = .013). Among children with pain who used CAM, the 2 most commonly used CAM modalities were biology-based therapies (47.3%) (eg, special diets and herbal supplements) and manipulative or body-based therapies (46.3%) (eg, chiropractic and massage).CAM is frequently used by children with pain in the United States, and many parents report benefits for their child's symptoms.

    View details for DOI 10.1016/j.acap.2017.02.008

    View details for Web of Science ID 000411921700012

    View details for PubMedID 28232257

    View details for PubMedCentralID PMC5598558

  • Codeine use among children in the United States: a nationally representative study from 1996 to 2013. Paediatric anaesthesia Livingstone, M. J., Groenewald, C. B., Rabbitts, J. A., Palermo, T. M. 2017; 27 (1): 19-27


    Concerns regarding the safety of codeine have been raised. Cases of life-threatening respiratory depression and death in children have been attributed to codeine's polymorphic metabolic pathway. International health agencies recommend restricted use of codeine in children. Despite these recommendations, the epidemiology of codeine use among children remains unknown.Our objective was to examine patterns of codeine use in the US among children.A cross-sectional analysis of children of age 0-17 years from 1996 to 2013 in the US was performed. Data were extracted from MEPS, a nationally representative set of health care surveys. Prevalence rates of codeine use between 1996 and 2013 were examined. Multivariable logistic regression examined relationships between codeine use and patient demographics.Codeine use remained largely unchanged from 1996 to 2013 (1.08 vs 1.03 million children, respectively). Odds of codeine use was higher in ages 12-17 (OR, 1.40; [1.21-1.61]), outside of the Northeastern US, and among those with poor physical health status (OR, 3.29 [1.79-6.03]). Codeine use was lower in children whose ethnicity was not white and those uninsured (OR, 0.47 [0.34-0.63]). Codeine was most frequently prescribed by emergency physicians (18%) and dentists (14%). The most common condition associated with codeine use was trauma-related pain.Pediatric codeine use has declined since 1996; however, more than 1 million children still used codeine in 2013. Health care providers must be made aware of guidelines advising against the use of codeine in children. Codeine is potentially hazardous and safer alternatives to treat children's pain are available.

    View details for DOI 10.1111/pan.13033

    View details for PubMedID 27779367

    View details for PubMedCentralID PMC5179302

  • Chronic pain in adolescence and internalizing mental health disorders: a nationally representative study PAIN Noel, M., Groenewald, C. B., Beals-Erickson, S. E., Gebert, J., Palermo, T. M. 2016; 157 (6): 1333-1338


    Chronic pain in childhood and adolescence has been shown to heighten the risk for depressive and anxiety disorders in specific samples in adulthood; however, little is known about the association between a wider variety of chronic pains and internalizing mental health disorders. Using nationally representative data, the objectives of this study were to establish prevalence rates of internalizing mental health disorders (anxiety and depressive disorders) among cohorts with or without adolescent chronic pain, and to examine whether chronic pain in adolescence is associated with lifetime history of internalizing mental health disorders reported in adulthood. Data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) was used (N = 14,790). Individuals who had chronic pain in adolescence subsequently reported higher rates of lifetime anxiety disorders (21.1% vs 12.4%) and depressive disorders (24.5% vs 14.1%) in adulthood as compared with individuals without a history of adolescent chronic pain. Multivariate logistic regression confirmed that chronic pain in adolescence was associated with an increased likelihood of lifetime history of anxiety disorders (odds ratio: 1.33; 95% confidence interval: 1.09-1.63, P = 0.005) and depressive disorders (odds ratio: 1.38; confidence interval: 1.16-1.64, P < 0.001) reported in adulthood. Future research is needed to examine neurobiological and psychological mechanisms underlying these comorbidities.

    View details for DOI 10.1097/j.pain.0000000000000522

    View details for Web of Science ID 000378876300020

    View details for PubMedID 26901806

    View details for PubMedCentralID PMC4939835

  • Association Between Widespread Pain Scores and Functional Impairment and Health-Related Quality of Life in Clinical Samples of Children JOURNAL OF PAIN Rabbitts, J. A., Holley, A., Groenewald, C. B., Palermo, T. M. 2016; 17 (6): 678-684


    Pain involving several body regions generally represents nervous system pathophysiology shifting from predominantly peripheral to more central. In adults, higher widespread pain scores are clinically meaningful and confer risk for poor response to treatment. It is unknown whether widespread pain is similarly important in children. To address this gap, we conducted an observational study examining 1) associations between widespread pain and functional impairment and health-related quality of life (HRQOL) in clinical pediatric samples, and 2) associations among sociodemographic factors and pain catastrophizing with widespread pain scores. Participants were 166 children aged 10 to 18 years from 3 samples (acute pain, presurgery, chronic pain). Children self-reported pain intensity, pain catastrophizing, functional impairment, and HRQOL. Children indicated pain locations on a body diagram, which was coded using the American College of Rheumatology definition of widespread pain. Results revealed higher widespread pain scores were associated with greater functional impairment with routine activities (F = 3.15, P = .02) and poorer HRQOL (F = 3.29, P = .02), adjusting for pain intensity, study group, and demographic characteristics. Older age (B = .11, P = .02), and Hispanic ethnicity (B = .67, P = .04) were associated with higher widespread pain scores. Findings support incorporating evaluation of widespread pain into pediatric pain assessment. Future research is needed to examine the longitudinal effect of widespread pain on children's treatment outcomes.This article examines the association between widespread pain scores and functional impairment and HRQOL in community and clinical samples of children. Assessment of the spatial distribution of the pain experience provides unique information that may identify children at risk for poorer health.

    View details for DOI 10.1016/j.jpain.2016.02.005

    View details for Web of Science ID 000377628000005

    View details for PubMedID 26924379

    View details for PubMedCentralID PMC4885772

  • Trends in opioid prescriptions among children and adolescents in the United States: a nationally representative study from 1996 to 2012. Pain Groenewald, C. B., Rabbitts, J. A., Gebert, J. T., Palermo, T. M. 2016; 157 (5): 1021-1027


    Prescription opioid misuse is a major public health concern in the United States, yet little is known about national prescription patterns. We aimed to assess trends in opioid prescriptions made to children and adolescents, to their families, and to adults in the United States from 1996 to 2012. The sample was drawn from nationally representative data, the Medical Expenditure Panel Surveys. We used survey design methods to examine trends in prescription opioid use over time and a logistic regression analysis to examine predictors associated with opioid use. Findings indicated that from 1996 to 2012 opioid prescriptions to children and adolescents remained stable and low. In 1996, 2.68% of children received an opioid prescription, and in 2012, 2.91% received an opioid prescription. In contrast, opioid prescriptions to family members of children and adolescents and adults in general significantly increased during this period. The most common opioid prescriptions to children and adolescents in 2012 were codeine, hydrocodone, and oxycodone. Using multivariate logistic regression models, the white non-Hispanic race, older age, health insurance, and parent-reported fair to poor general health were associated with higher rates of opioid prescriptions in children and adolescents. Our main finding was that although the rates of opioid prescriptions have increased among adults in the United States, the rates have not changed among children and adolescents. Recent epidemiologic association studies have identified a strong link between increased opioid prescriptions and increased rates of opioid misuse and abuse in adults. Future studies should assess the association between adult opioid prescriptions and children or adolescent opioid misuse.

    View details for DOI 10.1097/j.pain.0000000000000475

    View details for PubMedID 26716995

    View details for PubMedCentralID PMC4943214

  • Legitimate opioid prescription increases the risk for future opioid misuse in some adolescents. Evidence-based nursing Groenewald, C., Palermo, T. 2016; 19 (3): 83

    View details for DOI 10.1136/ebnurs-2016-102312

    View details for PubMedID 27056838

  • Trajectories of postsurgical pain in children: risk factors and impact of late recovery on long-term health outcomes after major surgery PAIN Rabbitts, J. A., Zhou, C., Groenewald, C. B., Durkin, L., Palermo, T. M. 2015; 156 (11): 2383-2389


    Over 1 million children undergo inpatient surgery annually in the United States. Emerging research indicates that many children have longer-term problems with pain. However, limited data exist on the course of pain over time and the impact of pain recovery on long-term health outcomes. We sought to prospectively characterize children's postsurgical pain trajectories using repeated assessments over 12 months. In addition, we identified presurgical child and parent psychological risk factors associated with persistent pain and examined relationships between pain trajectories and long-term health outcomes. Sixty children aged 10 to 18 years undergoing major surgery and their parent/guardian were enrolled. Participants completed assessments at 5 time points: presurgery, inhospital, 2 weeks, 4 months, and 1 year postsurgery. Child and parent pain catastrophizing was assessed during the week before surgery. Children completed daily monitoring with an electronic pain diary and reported on pain characteristics, health-related quality of life, and activity limitations. Group-based longitudinal modeling revealed 2 distinct trajectories of postsurgical pain: early recovery (n = 49, 82%) and late recovery (n = 11, 18%). In a logistic regression model controlling for age and sex, parental pain catastrophizing before surgery significantly predicted membership in the late recovery group (odds ratio = 1.11, P = 0.03), whereas child catastrophizing and baseline pain did not (Ps < 0.05). In a multivariate regression controlling for age and sex, late pain recovery was significantly associated with poorer health-related quality of life (β = -10.7, P = 0.02) and greater activity limitations (β = 3.6, P = 0.04) at 1 year. Our findings suggest that preoperative interventions that modify parent behaviors and cognitions might be beneficial in this population.

    View details for DOI 10.1097/j.pain.0000000000000281

    View details for Web of Science ID 000364110700031

    View details for PubMedID 26381701

    View details for PubMedCentralID PMC4607609

  • Alcohol and Tobacco Use in Youth With and Without Chronic Pain JOURNAL OF PEDIATRIC PSYCHOLOGY Law, E. F., Bromberg, M. H., Noel, M., Groenewald, C., Murphy, L. K., Palermo, T. M. 2015; 40 (5): 509-516


    To compare rates of alcohol and tobacco use in youth with and without chronic pain and to identify risk factors for use.Participants included 186 youth (95 mixed chronic pain; 91 without chronic pain; 12-18 years old) who reported current alcohol and tobacco use, pain intensity, activity limitations, loneliness, and depressive symptoms.Adolescents with chronic pain were less likely to use alcohol compared with adolescents without chronic pain (7.4% vs. 22%), and as likely to use tobacco (9% vs. 8%). Across groups, youth with higher depressive symptoms, less loneliness, and fewer activity limitations were more likely to endorse alcohol and tobacco use. Exploratory analyses revealed that risk factors for substance use differed among youth with and without chronic pain.Chronic pain may not increase risk for tobacco and alcohol use in adolescents. Research is needed to understand use of other substances in this medically vulnerable population.

    View details for DOI 10.1093/jpepsy/jsu116

    View details for Web of Science ID 000358088100005

    View details for PubMedID 25617047

    View details for PubMedCentralID PMC4635627

  • Health care expenditures associated with pediatric pain-related conditions in the United States PAIN Groenewald, C. B., Wright, D. R., Palermo, T. M. 2015; 156 (5): 951-957


    The primary objective of this study was to assess the impact of pediatric pain-related conditions on health care expenditures. We analyzed data from a nationally representative sample of 6- to 17-year-old children captured in the 2007 National Health Interview Survey and 2008 Medical Expenditure Panel Survey. Health care expenditures of children with pain-related conditions were compared with those of children without pain-related conditions. Pain-related conditions were associated with incremental health care expenditures of $1339 (95% confidence interval [CI], $248-$2447) per capita. Extrapolated to the nation, pediatric pain-related conditions were associated with $11.8 billion (95% CI, $2.18-$21.5 billion) in total incremental health care expenditures. The incremental health care expenditures associated with pediatric pain-related conditions were similar to those of attention deficit and hyperactivity disorder ($9.23 billion; 95% CI, $1.89-$18.1 billion), but more than those associated with asthma ($5.35 billion; 95% CI, $0-$12.3 billion) and obesity ($0.73 billion; 95% CI, $6.28-$8.81 billion). Health care expenditures for pediatric pain-related conditions exert a considerable economic burden on society. Efforts to prevent and treat pediatric pain-related conditions are urgently needed.

    View details for DOI 10.1097/j.pain.0000000000000137

    View details for Web of Science ID 000354007800022

    View details for PubMedID 25734992

    View details for PubMedCentralID PMC4607282

  • Presurgical Psychosocial Predictors of Acute Postsurgical Pain and Quality of Life in Children Undergoing Major Surgery JOURNAL OF PAIN Rabbitts, J. A., Groenewald, C. B., Tai, G. G., Palermo, T. M. 2015; 16 (3): 226-234


    Limited research has examined presurgical risk factors for poor outcomes in children after major surgery. This longitudinal study examined presurgical psychosocial and behavioral factors as predictors of acute postsurgical pain intensity and health-related quality of life (HRQOL) in children 2 weeks after major surgery. Sixty children aged 10 to 18 years, 66.7% female, and their parent/guardian participated in the study. Children underwent baseline assessment of pain (daily electronic diary), HRQOL, sleep (actigraphy), and psychosocial factors (anxiety, pain catastrophizing). Caregivers reported on parental pain catastrophizing. Longitudinal follow-up assessment of pain and HRQOL was conducted at home 2 weeks after surgery. Regression analyses adjusting for baseline pain revealed that presurgery sleep duration (β = -.26, P < .05) and parental pain catastrophizing (β = .28, P < .05) were significantly associated with mean pain intensity reported by children 2 weeks after surgery, with shorter presurgery sleep duration and greater parental catastrophizing about child pain predicting greater pain intensity. Adjusting for baseline HRQOL, presurgery child state anxiety (β = -.29, P < .05) was significantly associated with HRQOL at 2 weeks, with greater anxiety predicting poorer HRQOL after surgery. In conclusion, child anxiety, parental pain catastrophizing, and sleep patterns are potentially modifiable factors that predict poor outcomes in children after major surgery.This study addresses an important gap in literature, examining presurgical risk factors for poorer acute postsurgical outcomes in children undergoing major surgery. Knowledge of these factors will enable presurgical identification of children at risk for poorer outcomes and guide further research developing prevention and intervention strategies for these children.

    View details for DOI 10.1016/j.jpain.2014.11.015

    View details for Web of Science ID 000351027300004

    View details for PubMedID 25540939

    View details for PubMedCentralID PMC5137504

  • The price of pain: the economics of chronic adolescent pain PAIN MANAGEMENT Groenewald, C. B., Palermo, T. M. 2015; 5 (2): 61-64

    View details for DOI 10.2217/PMT.14.52

    View details for Web of Science ID 000362669100001

    View details for PubMedID 25806898

    View details for PubMedCentralID PMC4562402

  • The Economic Costs of Chronic Pain Among a Cohort of Treatment-Seeking Adolescents in the United States JOURNAL OF PAIN Groenewald, C. B., Essner, B. S., Wright, D., Fesinmeyer, M. D., Palermo, T. M. 2014; 15 (9): 925-933


    The aim of this study was to assess the economic cost of chronic pain among adolescents receiving interdisciplinary pain treatment. Information was gathered from 149 adolescents (ages 10-17) presenting for evaluation and treatment at interdisciplinary pain clinics in the United States. Parents completed a validated measure of family economic attributes, the Client Service Receipt Inventory, to report on health service use and productivity losses due to their child's chronic pain retrospectively over 12 months. Health care costs were calculated by multiplying reported utilization estimates by unit visit costs from the 2010 Medical Expenditure Panel Survey. The estimated mean and median costs per participant were $11,787 and $6,770, respectively. Costs were concentrated in a small group of participants; the top 5% of those patients incurring the highest costs accounted for 30% of total costs, whereas the lower 75% of participants accounted for only 34% of costs. Total costs to society for adolescents with moderate to severe chronic pain were extrapolated to $19.5 billion annually in the United States. The cost of adolescent chronic pain presents a substantial economic burden to families and society. Future research should focus on predictors of increased health services use and costs in adolescents with chronic pain.This cost of illness study comprehensively estimates the economic costs of chronic pain in a cohort of treatment-seeking adolescents. The primary driver of costs was direct medical costs followed by productivity losses. Because of its economic impact, policy makers should invest resources in the prevention, diagnosis, and treatment of chronic pediatric pain.

    View details for DOI 10.1016/j.jpain.2014.06.002

    View details for Web of Science ID 000350618400005

    View details for PubMedID 24953887

    View details for PubMedCentralID PMC4150826

  • Sympathetic Support of Energy Expenditure and Sympathetic Nervous System Activity After Gastric Bypass Surgery OBESITY Curry, T. B., Somaraju, M., Hines, C. N., Groenewald, C. B., Miles, J. M., Joyner, M. J., Charkoudian, N. 2013; 21 (3): 480-485


    This study was designed to determine how gastric bypass affects the sympathetically-mediated component of resting energy expenditure (REE) and muscle sympathetic nerve activity (MSNA).We measured REE before and after beta-blockade in seventeen female subjects approximately three years post-gastric bypass surgery and in nineteen female obese individuals for comparison. We also measured MSNA in a subset of these subjects.The gastric bypass subjects had no change in REE after systemic beta-blockade, reflecting a lack of sympathetic support of REE, in contrast to obese subjects where REE was reduced by beta-blockade by approximately 5% (P < 0.05). The gastric bypass subjects, while still overweight (BMI = 29.3 vs 38.0 kg·m(-2) for obese subjects, P < 0.05), also had significantly lower MSNA compared to obese subjects (10.9 ± 2.3 vs. 21.9 ± 4.1 bursts·min(-1) , P < 0.05). The reasons for low MSNA and a lack of sympathetically mediated support of REE after gastric bypass are likely multifactorial and may be related to changes in insulin sensitivity, body composition, and leptin, among other factors.These findings may have important consequences for the maintenance of weight loss after gastric bypass. Longitudinal studies are needed to further explore the changes in sympathetic support of REE and if changes in MSNA or tissue responsiveness are related to the sympathetic support of REE.

    View details for DOI 10.1002/oby.20106

    View details for Web of Science ID 000322087600033

    View details for PubMedID 23592656

    View details for PubMedCentralID PMC3630471

  • Outcomes of general anesthesia for noncardiac surgery in a series of patients with Fontan palliation PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Mauermann, W. J., Barbara, D. W., Burkhart, H. M., Warnes, C. A., Oliver, W. C., Flick, R. P. 2013; 23 (2): 180-187


    To describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery.The Fontan procedure was developed in 1971 to palliate patients with univentricular cardiac physiology leading to long-term survival of these patients, who may now present as adults for noncardiac surgery.We retrospectively reviewed the medical records of Fontan patients 16 years and older who underwent general anesthesia for noncardiac surgery at Mayo Clinic in Rochester, Minnesota. Preoperative data, perioperative course, intraoperative and postoperative hemodynamic, pulmonary, cardiovascular, and renal complications were described.Thirty-nine general anesthetics were administered to 31 patients for noncardiac surgery after Fontan palliation. Perioperative complications occurred in 12 of the 39 (31%) noncardiac surgeries, and there was one postoperative death that occurred on day 13 after ventral hernia repair. The two patients who had complications that did not resolve (long-term dialysis and death) had ejection fractions well below the mean for the group (22% and 28%).It may be more appropriate for Fontan patients to undergo anesthesia for noncardiac surgery in a tertiary institution, particularly patients with an ejection fraction of <30%. Intraoperative arterial blood pressure monitoring and overnight admission are likely appropriate for most cases.

    View details for DOI 10.1111/pan.12020

    View details for Web of Science ID 000313051800013

    View details for PubMedID 22998356

  • An unexpected cause of cardiac arrest during laparoscopy in an infant with supravalvar aortic stenosis PEDIATRIC ANESTHESIA Groenewald, C. B., Latham, G. J. 2013; 23 (1): 91-93


    Patients with congenital supravalvar aortic stenosis (SVAS) with associated biventricular outflow tract obstruction and coronary artery abnormalities have a tenuous myocardial oxygen supply/demand relationship. They are at increased risk of acute myocardial ischemia and sudden death, especially during anesthesia. Furthermore, resuscitation during cardiac arrest is frequently unsuccessful. We report a case of perioperative cardiac arrest due to an unexpected cause in a 2 month old with SVAS during a laparoscopic Nissen fundoplication.

    View details for DOI 10.1111/pan.12069

    View details for Web of Science ID 000312136400015

    View details for PubMedID 23137064

  • Geographic differences in perioperative opioid administration in children PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Raesaenen, J. 2012; 22 (7): 676-681


    To investigate whether geographic differences exist in perioperative opioid administration to children.  To investigate whether perioperative fentanyl use for cleft lip and palate surgery varies between children of three different geographic regions.Differences have been found in perioperative opioid administration to children of differing ethnicity in the USA. Whether similar differences exist in perioperative opioid administration to children residing in different geographic regions is unknown.We retrospectively reviewed the medical records of ASA I children who underwent surgery under standardized general anesthesia between January 2010 and April 2011 during SMILE Network International mission trips to Africa, India and Central and South America. Perioperative administration of fentanyl was compared between these three locations.We analyzed data from 79 children who underwent surgery in Africa, 76 in India and 153 in Central and South America. Children in Central and South America were given <50% of the intraoperative amount of fentanyl (2.0 ± 1.2 mcg·kg(-1) ) administered to children in Africa (4.1 ± 2.4 mcg·kg(-1) ; P < 0.001) and children in India (4.3 ± 2.2 mcg·kg(-1) ; P < 0.001). Postoperatively, fentanyl was administered in equivalent doses to all groups.Children in Central and South America received less opioid intraoperatively than African and Indian children, under standardized anesthesia for cleft surgeries. Further research is necessary to elucidate the mechanisms underlying these group differences.

    View details for DOI 10.1111/j.1460-9592.2012.03806.x

    View details for Web of Science ID 000304714500009

    View details for PubMedID 22324378

    View details for PubMedCentralID PMC5139618

  • Prevalence of moderate-severe pain in hospitalized children PEDIATRIC ANESTHESIA Groenewald, C. B., Rabbitts, J. A., Schroeder, D. R., Harrison, T. E. 2012; 22 (7): 661-668


      Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown.  We reviewed clinical characteristics of all pediatric patients admitted to Mayo Eugenio Litta Children's hospital during July 2009. Patients with moderate-severe pain were identified. For patients identified as having moderate-severe pain risk factors, analgesia regimens, and pain outcomes were reviewed.  The prevalence of moderate-severe in-hospital pain was 27% (95% C.I. 23% to 32%). Teenagers and infants experienced higher prevalence rates of moderate-severe pain (38% and 32% respectively) than children (17%, P < 0.001). In addition, patients admitted to medical services had much lower rates of moderate-severe pain (13%) than those admitted to surgical services (44%, P < 0.001). Regional anesthesia was used in eleven (7.2%) of the patients on surgical services. Acetaminophen was administered to 75% of patients with moderate-severe pain. Only 21% of these patients had nonsteroidal anti-inflammatory drugs (NSAIDS) available. Opioids were given scheduled to 36% of patients with moderate-severe pain and as needed to another 40%. Fifty-five percent of patients still had one or more episode of moderate-severe pain on the day following an initial diagnosis; however, this number decreased steadily over subsequent days. Eleven patients (13% of those diagnosed with moderate-severe pain) still had one or more episodes of daily moderate-severe pain by day four.  The prevalence of moderate-severe pain in hospitalized children remains high. Analgesia regimens may not be optimal. Underutilization of regional anesthesia techniques may have contributed to increased pain scores. A large proportion of children diagnosed with moderate-severe pain may have persistent clinically significant pain in subsequent days.

    View details for DOI 10.1111/j.1460-9592.2012.03807.x

    View details for Web of Science ID 000304714500007

    View details for PubMedID 22332912

  • Postural orthostatic tachycardia syndrome and general anesthesia: a series of 13 cases JOURNAL OF CLINICAL ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Jacob, A. K., Low, P. A., Curry, T. B. 2011; 23 (5): 384-392


    To investigate whether patients with postural orthostatic tachycardia syndrome (POTS) developed unexpected perioperative complications.Retrospective case series.Academic medical center.The records of 13 patients with POTS, who underwent surgical procedures during general anesthesia, were studied. Details of disease management, anesthetic induction, hemodynamic response to induction and intubation, intraoperative course, and immediate postoperative management were analyzed.Three patients developed prolonged intraoperative hypotension, which was not associated with induction of anesthesia. All 13 patients were successfully treated and they recovered without complications. There were no unplanned hospital or intensive care admissions.Intraoperative hypotension, but not tachycardia, was observed in three of 13 patients with POTS who received general anesthesia for a variety of surgical procedures using multiple medications and techniques.

    View details for DOI 10.1016/j.jclinane.2010.12.013

    View details for Web of Science ID 000293940000007

    View details for PubMedID 21802629

    View details for PubMedCentralID PMC3349351

  • Perioperative opioid requirements are decreased in hypoxic children living at altitude PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Dietz, N. M., Morales, C., Raesaenen, J. 2010; 20 (12): 1078-1083


    To investigate the effect of altitude on perioperative opioid requirements in otherwise healthy children.To investigate whether children living and having surgery at high altitude received different doses of fentanyl than those living and having surgery at sea level.Recent studies in animals (Anesthesiology, 105, 2006 and 715) and children with obstructive sleep apnea (Anesthesiology, 105, 2006 and 665; Anesthesiology 100, 2004 and 806) suggest that analgesic effects of exogenous opioids are enhanced by hypoxia. However, the effects of hypoxia on perioperative narcotic requirements in otherwise healthy children have not been previously reported.We reviewed retrospectively the opioid requirements of pediatric patients who underwent cleft lip or palate surgery during Smile Network International mission trips to Cusco and Lima, Peru between 2007 and 2009. Patients who had surgery at high altitude were compared to those who had surgery at sea level. All patients received a standardized anesthetic with intravenous fentanyl as the only perioperative opioid.Hundred and two patients had surgery at 3399 m above sea level (masl) (Cusco) and 169 patients had surgery at 150 masl (Lima). Patients at high altitude had significantly lower baseline oxygen saturations (92 ± 4% vs 98 ± 3%; P < 0.001) and received 40% less opioid (1.2 ± 0.8 vs 2.0 ± 1.4 μg·kg(-1) per h; P < 0.001) compared to patients at sea level.Opioid administration was reduced in otherwise healthy children with altitude-induced chronic hypoxia when compared to non-hypoxic children undergoing similar operations under similar anesthetic regimens. Whether this difference is due to altitude or altitude-induced hypoxia, requires further study.

    View details for DOI 10.1111/j.1460-9592.2010.03453.x

    View details for Web of Science ID 000284485500003

    View details for PubMedID 21199116

  • Epidemiology of Ambulatory Anesthesia for Children in the United States: 2006 and 1996 ANESTHESIA AND ANALGESIA Rabbitts, J. A., Groenewald, C. B., Moriarty, J. P., Flick, R. 2010; 111 (4): 1011-1015


    There are few data that describe the frequency, anesthetic type, provider, or disposition of children requiring outpatient anesthesia in the United States (US). Since the early 1980s, the frequency of ambulatory surgery has increased dramatically because of advances in medical technology and changes in payment arrangements. Our primary aim in this study was to quantify the number of ambulatory anesthetics for children that occur annually and to study the change in utilization of pediatric anesthetic care over a decade.The US National Center for Health Statistics performed the National Survey of Ambulatory Surgery in 1994 through 1996 and again in 2006. The survey is based on data abstracted from a national sample of ambulatory surgery centers and provides data on visits for surgical and nonsurgical procedures for patients of all ages. We abstracted data for children who had general anesthesia, regional anesthesia, or monitored anesthesia care during the ambulatory visit. We obtained the information from the 2006 and 1996 databases and used population census data to estimate the annual utilization of ambulatory anesthesia per 1000 children in the US.In 2006, an estimated 2.3 million ambulatory anesthesia episodes of care were provided in the US to children younger than 15 years (38 of 1000 children). This amount compares with 26 per 1000 children of the same age group in 1996. In most cases, an anesthesiologist was involved in both time periods (74% in 2006 and 85% in 1996). Of the children, 14,200 were admitted to the hospital postoperatively, a rate of 6 per 1000 ambulatory anesthesia episodes.The number and rate of ambulatory anesthesia episodes for US children increased dramatically over a decade. This study provides an example of how databases can provide useful information to health care policy makers and educators on the utilization of ambulatory surgical centers by children.

    View details for DOI 10.1213/ANE.0b013e3181ee8479

    View details for Web of Science ID 000282310200031

    View details for PubMedID 20802051

  • Patient Records at Mayo Clinic: Lessons Learned From the First 100 Patients in Dr Henry S. Plummer's Dossier Model MAYO CLINIC PROCEEDINGS Camp, C. L., Smoot, R. L., Kolettis, T. N., Groenewald, C. B., Greenlee, S. M., Farley, D. R. 2008; 83 (12): 1396-1399

    View details for DOI 10.4065/83.12.1396

    View details for Web of Science ID 000261542000014

    View details for PubMedID 19046561