American Academy of Pediatrics Releases First Clinical Practice Guideline for Opioid Prescription, Treatment

Today, during the American Academy of Pediatrics (AAP) 2024 National Conference and Exhibition in Orlando, Florida, the Academy published its first clinical practice guideline (CPG) to guide pediatricians in their prescribing of opioids.^1,2

Image credit: © TensorSpark | stock.adobe.com

The guideline and corresponding technical report that was published today in Pediatrics contain detailed specific instructions as to when these opioid medications should be prescribed for pain, while trying to reduce the long-term risks of opioid use disorder, poisoning, and overdose as much as possible.^1,2

In a remarkable shift in clinical practice, the newly published guide recommends that naloxone, which is used to reverse opioid overdoses, be routinely prescribed alongside every opioid prescription. This recommendation and the 11 other key action statements are backed up by evidence from randomized controlled trials, thorough observational studies, and expert opinion.^1,2

“We want pediatricians to prescribe opioids when they’re needed because untreated pain can lead to distress and psychological harm,” Scott Hadland, MD, MPH, MS, FAAP, lead author of the guideline, said in a news release from AAP. “At the same time, physicians need to take steps that reduce the long-term risk for addiction.”²

Overall, the guidelines recommend that clinicians utilize a multimodal approach to treat acute pain. This involves the appropriate use of nonpharmacologic therapies, nonopioid medications, and opioid medications, when necessary. Critically, the APA guidelines recommend that “opioids should not be prescribed as monotherapy for children or adolescents who have acute pain.”²

Another major goal of the guideline is to highlight and alleviate the disparities faced by minoritized groups regarding opioid treatment. Groups such as Black, Hispanic, and American Indian/Alaskan Native children and adolescents have opioid prescriptions filled at a much lower rate and less timely than White patients, and were less likely to receive follow-up pain medications, according to a 2023 study. These disparities in treatment, and those based on language, socioeconomic status, and other factors, are dissected in the CPG.^2,3

The CPG provides specific methods for prescribing opioids for acute pain management. Clinicians are recommended to prescribe immediate-release opioid formulations and begin with the lowest age- and weight-appropriate doses. Importantly, unless pain is related to trauma or surgery and is expected to be long-lasting, an initial supply of 5 or fewer days of opioid treatment should be prescribed.²

Restrictions on codeine or tramadol—opioids that are only FDA-approved for adults—are also recommended. The CGP advocates clinicians to not prescribe those two treatments for patients younger than 12 years old; adolescents 12 to 18 years of age who have comorbidities such as obesity or lung disease; to treat postsurgical pain after tonsillectomy or adenoidectomy in patients younger than 18 years; or for any breastfeeding patient. These restrictions are aimed to minimize the risks associated with opioid prescriptions in these vulnerable subgroups.²

“Opioids do remain an important tool for acute pain relief,” Rita Agarwal, MD, FAAP, FASA, an author of the CPG, said in the news release. “But there are times when acetaminophen and ibuprofen may be equally effective with fewer side effects, such as in procedures such as tonsillectomy, wisdom teeth removal, and fractures.”¹

A major reason for the publishing of these guidelines is the massive swing in pain management approaches over the last 2 decades, according to the investigators. Previously, the liberal use of opioids to treat pain was encouraged, with the common narrative being that individuals in pain cannot develop an opioid addiction.²

Now, opioids are increasingly involved in US overdose deaths, and “the proverbial pendulum swung widely.” By recommending a multimodal approach to pain treatment, the CPG aims to strike a middle ground between the use of opioids and the avoidance of serious complications after prescription.²

REFERENCES

1. American Academy of Pediatrics. American Academy of Pediatrics announces its first clinical practice guideline for opioid prescriptions. EurekAlert! News Release. Released September 30, 2024. Accessed September 30, 2024. https://www.eurekalert.org/news-releases/1058520

2. 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;e2024068752. doi:10.1542/peds.2024-068752

3. Flores MW, Sharp A, Lu F, et al. Examining racial/ethnic differences in patterns of opioid prescribing: results from an urban safety-net health care system. J Racial Ethn Health Disparities. 2023;1-11. doi:10.1007/s40615-023-01555-z