Written by Joshua Belfer
Spoon Feed
The American Academy of Pediatrics has released their first clinical practice guideline on opioid prescribing in children and adolescents. The 12 evidence-based key action statements outline safe practices for prescribing opioids for acute pain in the outpatient setting.
Key highlights from the clinical practice guidelines
Rates of opioid use disorder (OUD), poisoning, and overdoses have significantly increased among children and adolescents. Perhaps not surprisingly, rates of opioid prescriptions for pediatric patients have decreased since the early 2010’s. In an effort to guide clinicians in safe prescribing practices, but also to avoid the undertreatment of pain, the AAP released clinical practice guidelines for clinicians prescribing opioids to patients <21 years old for acute pain in outpatient settings. Below are some highlights of the action statements with additional context in italics:
- Key Action Statement 1: Acute pain should be treated with a multimodal approach using nonpharmacologic therapies, nonopioid medications, and, when needed, opioid medications.
Research has shown that pain from conditions such as tonsillectomy and acute fractures – traditionally thought to require opioids – can be effectively managed with nonopioid analgesics. - KAS 3: When opioids are prescribed, immediate-release formulations should be used at the lowest age- and weight-appropriate dose, and a course of 5 days or fewer should be used.
Immediate-release formulations are associated with a lower risk of OUD and overdose. - KAS 4: Codeine or tramadol should not be prescribed to:
- Children <12 years old.
- 12-18 year old children with obesity, obstructive sleep apnea, or severe lung disease.
- Post-surgical tonsillectomy/adenoidectomy pain in children <18 years old.
- Breastfeeding women.
Single-ingredient codeine medications and all tramadol-containing products are approved only for use in adults given their serious risk profile.
- KAS 6: Naloxone prescriptions and education should be provided to patients receiving opioid prescriptions, along with their families.
In the community setting, naloxone is most commonly available as a nasal spray and has become increasingly available for over-the-counter purchase. - KAS 7/8: Prescribers should educate caregivers about safe storage of medication and safe disposal of unused medications.
Safe medication storage practices can help to prevent both intentional and unintentional use and poisonings.
How will this change my practice?
The opioid epidemic has been tragic and has forced clinicians to think critically about our own opioid prescribing practices. The authors of the guideline make a good point, though, that we should be mindful of the pendulum swinging too far the other way, namely, avoiding the undertreatment of pain. The AAP clinical practice guideline is important in both reviewing safe practices for those who prescribe opioids for acute pain, along with highlighting the information that prescribers should discuss with patients and their families. As the authors state in the paper, there are many important areas for future research, including high-quality clinical trials to establish the ideal dosing and duration of opioid treatment, and the comparison of opioid and nonopioid medications.
Source
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
