In 2018, researchers at the Yale School of Medicine reported in JAMA Network Open that approximately 9,000 children and adolescents had died of opioid poisoning-from both prescription and illicit use-between 1999 and 2016. The data revealed that the pediatric mortality rate attributable to opioids tripled during that time, with the sharpest increases among adolescents ages 15 to 19 and children younger than four years old. These findings illustrate the need for better opioid stewardship among clinicians caring for children after surgery, according to the authors of new evidence-based guidelines for opioid prescribing in this vulnerable population in the January JAMA Surgery.
OPTIMIZING PAIN MANAGEMENT
Children and adolescents are routinely exposed to opioids at home, in school, and out in the community. These painkillers are frequently prescribed for children after surgery, yet opioid-prescribing practices vary widely across pediatric surgical specialties, underscoring a lack of clear prescribing guidance. In an attempt to develop such guidance, the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee and a panel of experts examined the role of prescription opioids in optimizing pain management while minimizing health risks in children and adolescents after surgery. They reviewed more than 14,500 articles focused on pediatric populations and convened for two days. The resulting guidelines include 20 statements that are intended to support opioid stewardship. From these, three major themes emerged, according to the authors: "the risks of opioid misuse and dependence in pediatric and adolescent populations are significant, there is strong evidence for use of nonopioid alternatives perioperatively, and education of patients and families regarding perioperative pain management before and after surgery is paramount."
THE RISKS OF PRESCRIBING OPIOIDS
The first six guideline statements focus on the dangers of prescribing opioids to adolescents. The authors note that their literature review revealed that a significant number of adolescents with access to opioids misuse or divert them (sell them or give them away) and may develop a dependency disorder. The most common source of these misused drugs is a health care professional who either prescribes the medication to the adolescent or to a friend or relative, who then diverts the drug to the adolescent. They also observe that there is a high correlation between adolescent opioid misuse and heroin use.
Responsible prescribing is fundamental to preventing abuse and addiction, and nobody disputes that careful supervision is necessary when patients use opioids. However, some health care professionals are concerned the guidelines could unintentionally lead to undermedicating children's postoperative pain.
Renee C.B. Manworren, PhD, APRN, PCNS-BC, AP-PMN, FAAN, director of nursing research and professional practice at the Ann and Robert H. Lurie Children's Hospital of Chicago, argues that the guidelines rely, to some extent, on supplanted information, such as the 2017 National Survey on Drug Use and Health (NSDUH). "The most recent survey data clearly show that pediatric opioid use was lower in 2018 and 2019, and the lowest since 1975," Manworren observes. Indeed, the 2019 NSDUH results indicate that past-year opioid misuse among adolescents 12 to 17 years of age fell steadily from 3.9% in 2015 to 2.3% in 2019.
She worries the guidelines overstate the risks associated with these potent medications and may deter health care professionals from prescribing them when no better alternative exists for managing postsurgery pain in children. "We are now below 1999 opioid prescribing rates," Manworren says, "and there has not been a new molecule for pain for over 20 years."
PROMOTING PERIOPERATIVE NONOPIOID ALTERNATIVES
Statements No. 7 through No. 14 in the guidelines promote the use of perioperative nonopioid regimens to relieve pain, facilitate recovery, and minimize opioid risks. The guidelines recommend the use of opioid-free medications and the targeted use of regional anesthesia. They also list surgical procedures that some young patients can recover from using opioid-free postoperative analgesia. For example, an opioid-free recovery is possible after pediatric surgeries for knee ligament repair and cochlear implantation, the authors point out, noting that nonopioid intravenous medications like ketorolac have shown benefits in children who've had an inguinal hernia repair and adenotonsillectomy.
WHEN OPIOIDS ARE NECESSARY
If used properly, opioids can be helpful and effective for acute pain management. Pain due to major surgery or burns, for instance, may need to be managed with opioids, and these medications are important in palliative care. There is also concern that undertreating a child or an adolescent's pain can lead to posttraumatic stress disorder and psychiatric problems later.
The authors of the guidelines urge health care professionals to consider options that minimize opioid use and take advantage of combination regimens that may offer synergistic benefits for intra- and postoperative pain management. They point to studies showing that a mix of nonopioid medications can be used to manage pain in children and may lead to fewer complications, such as respiratory depression. The authors of the guidelines endorse the Food and Drug Administration's recommendations to limit the use of codeine and tramadol in those younger than age 18.
PATIENT AND FAMILY EDUCATION
Statements No. 15 to No. 20 in the guidelines highlight the importance of patient and family education and engagement in safe pain management, especially when opioids are prescribed. The authors note that health care professionals spend less than six minutes educating patients and caregivers on pain management on the day of surgery. The process should begin prior to surgery and continue after discharge, they argue, noting that this can help alleviate parents'-and thus the child's-anxiety about the surgical procedure.
In addition, all health care professionals on the perioperative team must offer consistent messaging to avoid confusing patients and their families with contradictory advice. Children and their parents (or other caregivers) need to be told in plain, nonclinical language what to expect before and after surgery, so they are adequately prepared for all eventualities, including adverse effects and outcomes. The authors note that, according to the studies they reviewed, parents are more likely to administer opioids appropriately when they are educated on their adverse effects and the serious implications of these adverse effects, such as oversedation. Parental knowledge, say the guidelines' authors, is associated with better pain management strategies and positive attitudes toward pain medication use.
After caregivers and patients understand how potent opioids are, health care professionals must instruct them about secure storage and safe disposal. The authors of the guidelines note that one study found only 32.6% of adults with young children and 11.7% with older children said they store opioids safely. The tragic increase in the number of opioid-related deaths among teens and children ages four years and younger, cited in the Yale School of Medicine study, illustrates the need to store and secure these drugs, use childproof packaging, and safely dispose of any leftover doses. Yet, as noted in the guidelines, another study demonstrated that only 30% of adolescents' caregivers reported they disposed of the opioids, and 16% said they didn't know how to safely dispose of them.
The authors point out opportunities to improve disposal compliance and practices. These include the addition of a drug disposal container at local health care institutions, where parents can drop off excess medication, as well as education on the appropriate way to dispose of opioids at home (using drug deactivation compounds or disposal bags, for example).
ENSURING ADEQUATE PAIN MANAGEMENT
Manworren, who authored several studies cited in the new guidelines, supports the recommendations but is worried the heavy emphasis on misuse could undercut the treatment of children's pain. "While I wish no child misused opioids, guidelines for opioid prescribing for surgical pain should spell out both opioid risks and benefits," she says. "The benefits of opioids for pain relief are significant after surgery. These guidelines seek to minimize opioid use instead of minimizing both opioid use and pain."
Despite the criticism, the guidelines are timely and invite further study and discussion regarding optimal use of opioids in pediatric populations. The authors note that they anticipate updating the guidelines as new research emerges and providers become more aware of the need for improved opioid stewardship when managing pain in children and adolescents.-Lucy Wang Halpern