Top Pediatric Group Establishes Opioid Prescribing Guidelines for Kids

For the first time, the American Academy of Pediatrics has announced clear guidelines for how and when pediatricians and psychiatrists should prescribe opioids to children.

The news comes at the tail end of an era of the opioid crisis fueled by prescription pills including OxyContin, which were prescribed to millions of people even for routine surgeries like wisdom teeth removal, hundreds of thousands of whom subsequently became addicted or died.

The guidelines encourage providers to prescribe at the lowest dose for the shortest amount of time if opioids are needed, and to provide naloxone along with the prescription.

"Our hope is to have a more organized approach in general to managing pain," said Rita Agarwal, fellow of the American Academy of Pediatrics, clinical professor of anesthesiology at Stanford University and a pediatric anesthesiology and pain specialist at Lucille Packard Children's. "How do we treat pain in a way that's safe and effective?"

Agarwal said for years there's been confusion about whether to prescribe opioids to kids amid the crisis, and that this left many patients in real pain without relief. The guidelines should standardize prescribing and eliminate this confusion.

"In years past, I was taught that we undertreated pain, and this led to an era of overprescribing opioids, which was certainly not the right approach," said AAP spokesperson Katie Lockwood, a general pediatrician at Children's Hospital of Philadelphia.

"Then we swung in the opposite direction, and providers weren't prescribing it even when kids needed it. I think these guidelines are really helpful in giving providers some guidance on how to treat pain and mitigate addiction, finding that middle ground."

Abigail Schlesinger, clinical chief of child and adolescent psychiatry at UPMC Children's Hospital and Western Psychiatric Hospital, agreed that the guidelines help clarify what providers should and shouldn't be doing.

"You can individualize your care, but having a place to start allows you to provide a higher level of care," she said. "These are high-quality recommendations that, if they're not already being implemented, should help physicians and families."

Giving Narcan (generically, naloxone) along with an opioid prescription has already been standard practice at Children's Hospital of Philadelphia, said Lockwood, but adding it to the guidelines will further help chip away at the negative stigma associated with opioids and Narcan, as well as increase access to and education about the overdose-reversal medication.

Schlesinger noted that UPMC has been giving out naloxone for free at events for years.

According to one study by researchers in the pediatrics department at Yale, nearly 9,000 kids died of accidental opioid overdoses from 1999 to 2016, a mortality rate increase of 268%. While a majority of those deaths happened to youth between 15 and 19 years of age, opioids remain the most common cause of fatal overdoses in kids under the age of 5. Having Narcan in the home can protect against death caused by these accidental overdoses.

"There is no harm in prescribing Narcan, and it may very well save a life," said Agarwal.

Schlesinger said she was "pleasantly surprised" to see naloxone included in the guidelines.

In addition to recommending that opioids are prescribed at the lowest dose for the shortest amount of time if younger patients need them, the AAP guidelines also encourage education about safe use, storage and disposal.

"Having these medications in the house increases the risk of accidental overdose," said Lockwood. "These guidelines highlight the importance of safe storage and disposal of drugs."

And if a child's pain is mild, parents can mitigate it with acetaminophen (Tylenol), ibuprofen (Advil), heating pads and ice baths, per the guidelines.

"We wanted to include nonpharmacological approaches, like ice, heat, stretching, cognitive behavioral therapy and physical therapy," said Agarwal. "So that parents don't use opioids as the only analgesic."

Lockwood said these suggestions will help parents and providers get more granular about what pain is and what to expect.

And teaching kids to manage their own pain can help down the line, so they know how to help themselves, to a degree, if they get mildly hurt, said Schlesinger.

Having alternatives also opens up an opportunity for education about opioids and the harms of misuse early on. Talking with your child about why they might need opioids and for how long, as well as helping them understand why it's important not to misuse these medications can prevent substance use in adolescence, especially during the time when students are obtaining prescription pills that often contain highly potent fentanyl.

"As people adopt these guidelines, they may learn that there are often situations where [opioids] are not needed at all," said Agarwal.

Going forward, she said she hopes most physicians will adopt these guidelines and that confusion will dissipate and balance around opioid prescribing and pain management will develop.

"I am not anti-opioids," she said. "I use them a lot in my practice. I feel very strongly that we need to be very careful."

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