Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline Part 2
Myron Yaster MD, Elliot J. Krane MD, and Lynne G. Maxwell MD
The use of opioids in the treatment of moderate to severe acute pain has over the decades been a widely swinging pendulum: from liberal use in the 2000s to the current conservative practice to the point of paranoid prescription refusal/avoidance/dose limitations due to CDC pronouncements, draconian VA rules, fear of opioid abuse, opioid overdose deaths and DEA surveillance and prosecution of prescribers.
In today’s part 2 PAAD, Hadland et al.1 provide the American Academy of Pediatrics well balanced and very thoughtful clinical practice guideline on the management of acute pain in children and adolescents. Written primarily for pediatricians, many of the concepts like multimodal analgesia are essential components of your daily practice. The clinical guidelines have 9 key action items. In yesterday’s PAAD we reviewed the first 4. In today’s we will review the rest
Original article
Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics. 2024 Sep 30:e2024068752. doi: 10.1542/peds.2024-068752. Epub ahead of print. PMID: 39344439.
The stated goals of this clinical practice guideline are to maximize analgesia, limit the use of opioids, and reduce the risk of patients developing opioid use disorder. To be honest, we disagree with this supposition. Opioids have been used in the treatment of pain for over 5,000 years because they work! There is no question that they are associated with common (constipation, nausea/vomiting, pruritus, development of tolerance and dependence) and uncommon (respiratory depression/death) side effects. However, the link between the legitimate use of opioids and the development of opioid abuse and death is not as clear as these guidelines and our professional societies suggest. Indeed, in 2024 there really isn’t a connection between the legitimate use of opioids in the management of pain and the development of substance abuse disorder. And this is one of the paradoxes of current treatment strategies and these guidelines. Despite our successful efforts to reduce the quantities and duration of dispensed opioids, the risk of death from opioids has actually increased. Indeed, in 2024, opioid deaths are primarily the result of illicit fentanyl and not the non-medical use of prescribed opioids.2,3
5. When treating acute pain in children or adolescents who are taking sedating medications, such as benzodiazepines, pediatricians and other PHCPs should “use caution” when prescribing opioids. What does use caution mean exactly? Unfortunately, the guideline does not provide any clarity on this or recommendations, and it is unlikely that PHCPs will know how to interpret this recommendation. The combination of opioids and sedative hypnotics like the benzodiazepines potentiates respiratory depression.4,5 Yet in the outpatient setting, we think the most important sedative hypnotic to worry about in patients who overdose and develop respiratory depression is ALCOHOL; opioid prescribers need to think about this in at-risk teens and young adults.
6. When prescribing opioids, pediatricians and other PHCPs should provide naloxone and counsel patients and families on the signs of opioid overdose and on how to respond to an overdose. We’ve discussed the need to co-prescribe intranasal naloxone in several previous PAADs. (July 05, 2022 https://ronlitman.substack.com/p/naloxone-again ) (July 26, 2021 https://ronlitman.substack.com/p/a-pediatric-pharmacokinetic-study ), particularly in high risk groups. Indeed, we’ve urged all of you to not only co-prescribe naloxone for your outpatients receiving oral opioids but to also carry it on your person or store in your car for emergencies. It is now readily available even without a prescription (over the counter, OTC). The OTC cost is about $45 for a kit hat contains 2 naloxone inhalers. For families who cannot afford this drug OTC, prescriptions are almost always covered by insurance.
7. When prescribing opioids, pediatricians and other PHCPs should educate caregivers about safe storage and directly observed administration of medications to children and adolescents. “Safe medication storage is an important strategy to prevent poisonings in children; it is especially critical for opioids, which can be life threatening if young children ingest them, even in small amounts.”1
8. When prescribing opioids, pediatricians and other PHCPs should educate caregivers about safe disposal of unused medications, help caregivers develop a plan to safely dispose of unused medications, and, if possible, offer safe disposal in their practice. What to do with left over unconsumed opioids remains a vexing problem. Although the guidelines recommend take-back programs and mail-back programs, we don’t believe these work well enough or are used frequently enough. The most common suggestion is to flush the remainder down a toilet, or to mix with deactivating chemicals (usually charcoal). Both of these solutions place the opioids in the water supply and our are environmentally unsafe, yet remain the only easy and practical solution to this problem.6 (Of note, many Walgreens outlets now routinely dispense an envelope with a gel like-substance to be mixed with remaining opioids, and then placed in ordinary garbage to be sent to the landfill.)
9. When treating acute, worsened pain in children and adolescents with preexisting chronic pain, pediatricians and other PHCPs are well advised to prescribe opioids when indicated while partnering with other opioid-prescribing clinicians involved in the patient’s care, or with specialists in chronic pain, palliative care, and/or other opioid stewardship programs to determine an appropriate management plan. This is the area in which pediatric anesthesiologists, particularly those who work in pain services, can play a vital role. One specific challenge is the care of adolescents with OUD who are treated with buprenorphine or methadone. In general, it is important to define pain management goals when working with a patient with OUD. Consultation with an addiction specialist is ideal. Although, as discussed earlier in this CPG, opioids are not needed for many common procedures and injuries, some patients with an OUD may nonetheless require opioids in these and other circumstances. Alternatives include increasing buprenorphine or methadone doses to manage pain, or prescribing short-acting opioid medications that are administered in addition to their chronic medications for OUD. Patients with OUD who are on oral naltrexone (an opioid antagonist) who may need opioids postoperatively should discontinue the medication 48 to 72 hours before planned surgery; patients on long-acting injectable naltrexone may consider switching to the oral formulation at least 1 month before surgery and then discontinue the medication 48 to 72 hours before planned surgery. Some individuals with OUD may elect to avoid opioids entirely.1
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Hadland SE, Agarwal R, Raman SR, et al. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics 2024.
2. Szalavitz M. How Fentanyl Drove a Tsunami of Death in America. New York Times. 2024 09/27/2024.
3. Tanz LJ, Dinwiddie AT, Mattson CL, O'Donnell J, Davis NL. Drug Overdose Deaths Among Persons Aged 10-19 Years - United States, July 2019-December 2021. MMWR Morbidity and mortality weekly report 2022; 71(50): 1576-82.
4. Nichols DG, Walker LK, Wingard JR, et al. Predictors of acute respiratory failure after bone marrow transplantation in children. CritCare Med 1994; 22(9): 1485-91.
5. Chua KP, Brummett CM, Conti RM, Bohnert A. Association of Opioid Prescribing Patterns With Prescription Opioid Overdose in Adolescents and Young Adults. JAMA pediatrics 2020; 174(2): 141-8.
6. Yaster M, McNaull PP, Davis PJ. The opioid epidemic in pediatrics: a 2020 update. Current opinion in anaesthesiology 2020; 33(3): 327-34.