AAP Releases First Guidance on Outpatient Opioid Prescribing for Youths

ORLANDO — The American Academy of Pediatrics (AAP) rolled out its first clinical practice guideline detailing evidence-based approaches to safely prescribe opioids for children and adolescents with acute pain in outpatient settings.

The guideline describes when opioids may be indicated to treat acute pain in the pediatric population, and how to minimize associated risks, such as the potential for opioid use disorder, poisoning, and overdose.

Ultimately, the hope is that the new guideline will be “impactful for pediatricians,” Scott Hadland, MD, MPH, of Mass General for Children in Boston, said during the AAP annual meeting.

Both Hadland and co-author Rita Agarwal, MD, of Stanford University in California, noted that the guideline comes at a particularly relevant time. In the context of the opioid crisis and a decline in prescribing, an important question is whether the pendulum is “swinging too far back to the other side,” Agarwal said.

Pain tops the list of reasons why children and adolescents seek medical care, and inequities persist in the treatment of pain, she noted.

To help pediatricians and other pediatric healthcare providers address these issues, 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 its strength as a recommendation.

First, the guideline states that pediatricians should treat acute pain via a multimodal approach. This approach should include appropriate use of nonpharmacologic therapies and non-opioid medications, as well as opioid medications when needed (evidence grade B for randomized controlled trials or diagnostic studies “with minor limitations,” and “overwhelmingly consistent evidence from observational studies,” with a strong recommendation).

Meanwhile, pediatricians should not prescribe opioids as monotherapy for children and adolescents who have acute pain (grade B, with a strong recommendation).

Third, when prescribing opioids for acute pain in youths, pediatricians should provide immediate-release opioid formulations, start with the lowest appropriate doses for the patient’s age and weight, and provide an initial supply of 5 days or fewer, unless the pain is related to trauma or surgery with an expected duration of pain of more than 5 days (evidence grade C for observational studies, with a recommendation, albeit not a strong one).

Next, the following key action statements were all noted as strong recommendations with an evidence grade of X, meaning they represent “exceptional situations where validating studies cannot be performed” but for which “there is a clear preponderance of benefit or harm.”

These statements included that pediatricians should not prescribe codeine or tramadol when treating acute pain in children and adolescents younger than 12 years; acute pain in adolescents ages 12 to 18 who have obesity, obstructive sleep apnea, or severe lung disease; postsurgical pain after tonsillectomy or adenoidectomy in children and adolescents younger than 18; or acute pain in people of any age who are breastfeeding.

Moreover, when treating acute pain in youths who are taking sedating medications such as benzodiazepines, pediatricians should exercise caution when prescribing opioids (grade X, with a strong recommendation).

When prescribing opioids, pediatricians should provide naloxone (Narcan) and counsel patients and families on the signs of opioid overdose and how to respond to such an event (grade X, with a recommendation).

Additionally, pediatricians should educate caregivers about safe storage and directly observed administration to children and adolescents (evidence grade D for expert opinion, case reports, reasoning from first principles, with an optional recommendation).

Pediatricians should also educate caregivers about safe disposal of unused medications, and if possible, offer safe disposal in their practice (evidence grade A for well-designed randomized controlled trials or diagnostic studies on a relevant population, with a strong recommendation).

Finally, when treating “acute, worsened pain in children and adolescents with preexisting chronic pain,” pediatricians should prescribe opioids when indicated and “partner with any other opioid-prescribing clinicians involved in the patient’s care and with specialists in chronic pain, palliative care, and/or other opioid stewardship programs to determine an appropriate treatment plan” (grade D, with an optional recommendation).

In a technical report accompanying the clinical practice guideline, Sudha Raman, PhD, and Michael Smith, MD, MSCE, of Duke University School of Medicine in Durham, North Carolina, noted that “despite an extensive literature search … few [randomized controlled trials] were found related to the safety and efficacy of opioids in children with acute pain.”

Furthermore, studies that compared opioids versus no opioids “support the use of NSAIDs [nonsteroidal anti-inflammatory drugs] as first-line therapy for postoperative pain on the basis of similar pain control and fewer side effects,” they wrote.

“Similarly, few studies were found that assessed individual-, family-, or health systems-level interventions to increase safe outpatient opioid prescribing,” they added. However, they suggested that education of families and patients “can be an avenue to decrease risk associated with opioid prescription.”

Overall, randomized controlled trials and systematic reviews only covered a small portion of the clinical research questions used to develop the new guideline, Raman and Smith noted. “As a result, many of the [clinical practice guideline’s] key action statements are based on expert opinion and observational studies.”

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