Opioid
Loren Bonner
In the wake of the nation’s overdose crisis, some medical experts have worried that pain is being undertreated for the country’s youth as pediatricians prescribe fewer opioids.
A recent clinical practice guideline, published September 30, 2024, in Pediatrics, seeks to strike a balance between proper treatment and safety. The guideline is the first to detail evidence-based
approaches to safely prescribe opioids for children and adolescents with acute pain in outpatient settings.
“We wanted to make sure that opioids are used in cases in which a child or adolescent has severe acute pain and would benefit while also minimizing the risk of opioid medications,” said guideline author Scott Hadland, MD, from Mass General for Children and Harvard Medical School.
Opioids should not be prescribed as monotherapy for children or adolescents who have acute pain, wrote the guideline authors. When using opioids for acute pain management, they went on to say that clinicians should prescribe immediate-release opioid formulations, start with the lowest age- and weight-appropriate doses, and provide an initial supply of 5 or fewer days, unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days.
They also noted that clinicians should not prescribe codeine or tramadol to patients younger than 12 years old; to adolescents 12 to 18 years old who have obesity, obstructive sleep apnea, or severe lung disease; to treat postsurgical pain after tonsillectomy or adenoidectomy in patients younger than 18 years old; or for any breastfeeding patient.
According to the guideline, clinicians should treat acute pain using a multimodal approach that includes appropriate use of nonpharmacologic therapies, nonopioid medications, and opioids only when needed.
The new guideline consists of nine key action statements, which were assigned a letter score for the respective weight of evidence supporting them, as well as a description of their strength as a recommendation.
Health equity
Pain tops the list of reasons that children and adolescents seek medical care, and inequities persist in the treatment of pain, noted guideline authors.
The document seeks to alleviate disparate pain treatment of Black, Hispanic, and American Indian/Alaska Native children and adolescents “who receive pain management that is less adequate and less timely than that provided to white individuals,” said the guideline. There may also be disparities in pain treatment based on a patient’s language, socioeconomic status, geographic location, and other factors, which are discussed further in the guideline.
According to a 2021 study in Addiction, most children, adolescents, and young adults who received an opioid prescription did not progress to developing an OUD or experience an overdose.
According to the guideline, risk factors for OUD or overdose include prescriptions for long-acting opioids, high daily doses, and prescriptions with a duration of 1 week or longer.
Surgery was the most common reason a child or adolescent received an opioid prescription, with dentists and surgeons writing 61.4% of opioid prescriptions for children and adolescents younger than 21 years old.
In the community setting
“Opioids can and should be prescribed for severe acute pain in children,” said Hadland. “Additionally, pharmacists can counsel families on safe storage of opioids in their homes, and disposal of any unused medication afterwards.”
Having a medication disposal drop box on site at a pharmacy allows families to safely and conveniently dispose of unused opioids.
Pharmacists should also continue to speak with families about naloxone and recognizing the signs of an opioid overdose. ■
Further research and information needed for opioid prescribing
Authors of the guideline note that there are significant gaps and an urgent need for future research on a range of topics relevant to pediatricians and other pediatric health care providers, including:
- High-quality clinical trials to establish the ideal dosing and duration of treatment with opioids.
- High-quality clinical trials of opioids, nonopioid medications, and nonpharmacologic approaches.
- Studies in outpatient settings, particularly primary care.
- Clinical trials of pharmacogenetic and other genetic or molecular information to guide opioid prescribing.
- Studies of the cumulative impact of opioid exposure during childhood and adolescence.
- Examination of institutional policies that enhance or hinder appropriate opioid prescribing practices. ■