The American Academy of Pediatrics released its first clinical practice guideline on prescribing opioids for acute pain in children and adolescents in outpatient settings.
"As prescription opioids increasingly became involved in U.S. overdose deaths, the proverbial pendulum swung widely, and many clinicians and health systems inflexibly began refusing to offer opioids for pain—even in cases when these prescriptions were likely indicated," noted guideline authors. "These narratives and practices have harmed children and families across the country; the document seeks to provide a sensible path forward."
Key recommendations include:
- Using a multimodal approach to pain management, incorporating nonpharmacologic therapies and nonopioid medications.
- Avoiding opioid monotherapy for acute pain.
- Prescribing immediate-release opioid formulations at the lowest effective dose for 5 days or fewer, except in cases of trauma or surgery with expected longer pain duration.
- Not prescribing codeine or tramadol for children under 12, adolescents 12-18 with specific risk factors, or for postsurgical pain after tonsillectomy or adenoidectomy in patients under 18.
- Exercising caution when prescribing opioids to patients already taking sedating medications.
- Providing naloxone and educating caregivers on overdose recognition and response when opioids are prescribed.
- Educating caregivers about safe storage, administration, and disposal of opioids.
- Partnering with other clinicians and specialists for managing acute pain in patients with preexisting chronic pain.
Although pediatric opioid prescribing rates have decreased since peaking in the early 2010s, the decline may have encompassed both appropriate and inappropriate reductions. According to the AAP, in 2018, 8.9% of adolescents aged 15-19 years received at least one new opioid prescription, while 6.7% of children under 18 had filled an opioid prescription.
Recommendations, published in Pediatrics, were based on evidence from randomized controlled trials, observational studies, and, when high-quality research was unavailable, expert opinion. Specific guidance was provided on opioid selection, dosing, and duration of treatment for a variety of clinical scenarios.
For patients already on long-term opioid therapy for chronic pain, the guideline authors warned against abrupt discontinuation or rapid tapering, as this can lead to adverse outcomes like untreated pain, worsened mental health, and potential reliance on illicit opioids.
The AAP also suggested implementing clinical decision support tools in electronic health records to improve prescribing practices and monitoring of opioid metrics to address health equity.
The subcommittee called for more high-quality research on ideal opioid dosing and pain management protocols in outpatient settings.
"Pain research in children and adolescents has lagged behind that for adults, and clinical trials and high-quality observational studies addressing the knowledge gaps raised above are urgently needed," noted the guideline authors.
Author disclosures can be found in the published study.
