Orlando, FL—Pharmacists need to be aware of a new American Academy of Pediatrics (AAP) clinical guideline for pediatricians on prescribing opioids. The document includes specific instructions on how and when to prescribe these medications for pain while reducing the long-term risk of addiction.

One significance of the “Clinical Practice Guideline: Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings” is that it also recommends a routine prescription for naloxone to reverse overdoses when pediatric opioid prescriptions are filled.

The guideline and an accompanying technical report were published online recently by Pediatrics, simultaneous with the AAP 2024 National Conference & Exhibition in Orlando, Florida.

“There’s been a big pendulum swing in the practice of medicine over the last 2 decades—first with opioid-overprescribing, then with a huge cutback in opioid prescribing, likely leaving some children’s pain undertreated,” explained lead guideline author Scott Hadland, MD, MPH, MS, in a press release. “We want pediatricians to prescribe opioids when they’re needed because untreated pain can lead to distress and psychological harm. At the same time, physicians need to take steps that reduce the long-term risk for addiction.”

In 2018, 8.9% of adolescents aged 15 to 19 years had at least one new prescription for opioid medication in the preceding year. One-year prevalence rates for developing an opioid use disorder (OUD) or experiencing an overdose after a prescription range from 0.3% to 5.8%, according to the report.

Rates of OUD have increased dramatically since 2000 among children and adolescent, but at the same time, rates of prescribing of opioids have decreased since the 2010s. The authors suggested that not only is an indication of inappropriate use but also signals a decrease in potentially appropriate use.

The AAP clinical practice guideline recommends:

• Pediatricians can and should prescribe opioids; however, they should do so in conjunction with other nonpharmacologic approaches, such as physical therapy, to reduce pain and improve function. Opioids should also be prescribed alongside other nonopioid medications, including acetaminophen and ibuprofen
• Every prescription for opioids should also include a prescription for naloxone, an overdose-reversal medication. This is key to treating overdose in anyone in the household who takes too much opioid medication—not only the child to whom the medication is prescribed but other family members, including younger children in the house
• All children and teens should have equitable access to effective pain treatment. Black, Hispanic, American Indian, and Alaska Native individuals are less likely than white individuals to receive timely and effective pain management (including with opioids), even after accounting for the level of pain across a range of pain conditions—many of which result in severe acute pain
• Patients and caregivers should be given educational materials on pain-control therapies, opioids, and safe storage and disposal of medications. They should also receive teaching on how to recognize the signs of an opioid overdose and how to intervene
• The AAP outlines several restrictions around prescription of codeine and tramadol, which are only FDA-approved for use in adults. They should not be prescribed in children aged younger than 12 years; in patients aged 12 to 18 years with certain chronic conditions; in patients aged younger than 18 years after tonsillectomy or adenoidectomy; or in patients who are breastfeeding.

“For a patient with mild-to-moderate pain, doctors should always start nonopioid medications and treatment,” said guideline coauthor Rita Agarwal, MD. “Opioids do remain an important tool for acute pain relief. 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. We recommend that families talk with their pediatrician about options on how to best manage a child’s pain.”

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