Pain is among the most common symptoms for which pediatric patients seek care. The AAP has developed a new clinical practice guideline (CPG) to help pediatricians and pediatric health care providers safely treat acute pain with opioid medications in outpatient settings while avoiding unintended consequences.
While providers long have prescribed opioids to help treat pain, many recognize the potential harmful effects of these medications. Research shows the rates of opioid use disorder (OUD), poisoning and overdose have increased dramatically among U.S. children and adolescents in recent decades.
The new CPG Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings can help clinicians determine when to prescribe opioids and when to utilize alternative treatments.
The CPG and accompanying technical report Evidence for the Use of Opioid Medication for Pediatric Acute Pain in the Outpatient Setting are available at https://doi.org/10.1542/peds.2024-068752 and https://doi.org/10.1542/peds.2024-068753. They will be published in the November issue of Pediatrics.
Prevalence, risks of opioid prescribing
Opioid prescribing is relatively common in pediatrics. In 2018, 8.9% of adolescents 15-19 years old had at least one new prescription for opioid medication in the preceding year. Among children younger than 18 years, 6.7% had filled an opioid prescription from a medical provider, and 1.2% had one from a dentist. Surgery was the most common reason for being prescribed an opioid.
One-year prevalence rates for developing an OUD after a prescription range from 0.3% to 5.8%. The most common cause of poisoning and overdose deaths of children and teens continues to be illicitly manufactured fentanyl, rather than prescribed opioids. Fentanyl-related deaths among teens 10-19 years increased by 182% from 2019-’21. Nevertheless, inappropriate opioid prescribing likely contributed to increasing rates of negative opioid-related outcomes during the 2000s and early 2010s.
Multimodal approach
The central goal of the CPG is to aid clinicians in understanding when opioids may be indicated to safely treat acute pain in children and adolescents and how to minimize risks.
“Treating pain in children and adolescents is critical to compassionate care, and it’s essential that we address pain with the most effective treatments available, including opioids, when necessary,” said Scott E. Hadland, M.D., M.P.H., M.S., FAAP, a lead author of the CPG and chair of the CPG Subcommittee on Opioids. “When appropriately prescribed and monitored, opioids can play a vital role in managing severe pain, helping young patients recover and maintain their quality of life.”
The CPG calls for pediatricians and pediatric health care providers to treat acute pain using a multimodal approach, which includes the appropriate use of nonpharmacologic therapies, nonopioid medications and, when needed, opioid medications. Opioids should not be prescribed as monotherapy for children and adolescents who have acute pain.
Not all acute pain requires opioids. Clinicians should consider acetaminophen and nonsteroidal anti-inflammatory drugs, which may be equally effective with fewer side effects for many conditions, including tonsillectomy, wisdom teeth removal and fractures.
Equitable treatment
The guideline also seeks to alleviate disparate pain treatment for Black, Hispanic and American Indian/Alaska Native (AI/AN) children and adolescents compared to white individuals. In addition, children and adolescents with physical, developmental or intellectual disabilities may be less likely to receive effective pain management. The report also discusses disparities in pain treatment based on language, socioeconomic status, geographic location and other factors.
Studies show Black, Hispanic and AI/AN individuals receive less adequate and less timely pain management than that provided to white individuals, even when they experience similar levels of pain. Contributing factors include implicit bias on the part of treating clinicians, systemic racism in health care settings, patients’ mistrust of clinicians and health systems, cultural differences in experiencing and reporting pain, and language barriers.
“Addressing these inequities is not just a matter of fairness; it’s central to improving health outcomes for children across the country and ensuring that every child receives the care they deserve,” said Dr. Hadland, chief of the Division of Adolescent and Young Adult Medicine at Mass General for Children and an associate professor at Harvard Medical School.
Recommendations
Rita Agarwal, M.D., FAAP, a lead author of the CPG and vice chair of the CPG Subcommittee on Opioids, said development of the recommendations followed a thorough review of relevant research and close examination of the strength of existing studies and other documents.
“Given the increased recognition that the opioid crisis was not just an adult problem, but often started in adolescence, and that no such guidelines existed within the broader pediatric literature, the decision was made to proceed,” said Dr. Agarwal, clinical professor of anesthesiology at Stanford University School of Medicine and former chair of the AAP Section on Anesthesiology and Pain Medicine. “For many teens, their first exposure to prescription opioids is from their own friend’s or neighbor’s medicine cabinet.”
The CPG contains 12 key action statements, which are based on evidence from randomized controlled trials, high-quality observational studies and expert opinion, when studies are lacking or could not feasibly or ethically be conducted. The following are among the recommendations.
- Use a multimodal approach to treat acute pain that includes the appropriate use of nonpharmacologic therapies, nonopioid medications, and, when needed, opioid medications.
- Do not prescribe opioids as monotherapy for children and adolescents who have acute pain.
- If opioids are chosen as a treatment option, start with the lowest age- and weight-appropriate doses. Provide an initial supply of five days or fewer unless the pain is related to trauma or surgery with an expected duration of pain of more than five days.
- Do not prescribe codeine or tramadol to children younger than 12, patients ages 12-18 with certain chronic conditions such as obesity, patients younger than 18 after tonsillectomy or adenoidectomy, or patients who are breastfeeding.
- Instruct caregivers to observe administration of medications to children and adolescents.
- Educate caregivers about safe storage of medications and how to dispose of unused medications safely.
- When prescribing opioids, provide naloxone and counsel patients and families on the signs of opioid overdose and how to respond to an overdose.
Scott E. Hadland, M.D., M.P.H., M.S., FAAP, and Rita Agarwal, M.D., FAAP, will present a session titled “The New AAP Clinical Practice Guideline on Acute Pain Management and Use of Opioids in Outpatient Settings” from 2-3 p.m. EDT Sept. 30 at the AAP National Conference. For details, visit https://aapexperience24.eventscribe.net/.
Resources
Information for parents from HealthyChildren.org on managing a child’s pain after surgery
