Access to the PPM Journal and newsletters is FREE for clinicians.
14 Articles in Volume 18, Issue #9
Assessing Arthralgia in Children
Children, Opioids, and Pain: The Stats & Clinical Guidelines
How to Fit into a New Practice
How to Talk to Your Chronic Pain Patients
How to Treat Opioid Use Disorder in Pregnant Women
Intranasal Ketamine for Acute Pain in Children
Medication Selection for Comorbid Pain Management (Part 3)
MR Neurography: Using Peripheral Nerve Imaging as a Pain Diagnostic
Naloxone in Schools; Buprenorphine Conversions; OUD Management
Opioid Conversion Calculations and Changes
Pes Anserine Tendino-Bursitis as Primary Cause of Knee Pain in Overweight Women
Self-Management of Chronic Pain in Primary Care
The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

Children, Opioids, and Pain: The Stats & Clinical Guidelines

Consensus guidelines for prescribing opioids to children and adolescents are lacking.
Pages 18-20

Children in Pain: The Stats

  • Many studies suggest that chronic health problems, along with learning and developmental disorders, are on the rise among children. These rising conditions include, but are not limited to: attention-deficit disorder (ADHD), arthritis, asthma, autism spectrum disorder, auto-immune disorders, cancer, cardiovascular problems, cerebral palsy, cystic fibrosis, diabetes, epilepsy, food allergies, obesity, respiratory allergies, sickle cell anemia, and spina bifida.1
  • About 15% to 18% of children in the United States live with a chronic health condition,2 and approximately 5 to 38% of children and adolescents suffer from chronic pain.3
  • Up to 73% of children and adolescents with chronic pain will continue to have pain in adulthood and are likely to develop new pain conditions.3
  • According to the National Health and Nutrition Examination Survey data, 17% of US children, aged 4 to 18, experience frequent or severe headaches, including migraine, over the course of a year. Before puberty, boys and girls have headaches at approximately the same rate, but after age 12, the rate of recurrent and severe headaches rises among girls.4
  • Recent studies estimate that the economic cost of pediatric chronic pain in the US costs $19.5 billion annually and accounts for $11.8 billion in total incremental healthcare expenditures.5
  • Chronic pain negatively affects several functional domains in youth, including school attendance and peer relationships, and is associated with comorbid anxiety and/or depression.6
  • Children of parents with chronic pain reported significantly higher PTSD symptoms, as well as pain interference and lower health-related quality of life.6


Children on Opioids: The Data

  • Observational research shows significant increases in opioid prescriptions for pediatric populations from 2001 to 2010. Adolescents who misuse opioid pain medication often misuse medications from their own previous prescriptions, with an estimated 20% of adolescents with currently prescribed opioid medications reporting using them intentionally to get high or increase the effects of alcohol or other drugs. Misuse of opioid pain medications in adolescence strongly predicts later onset of heroin use.7
  • About 20% of children with chronic musculoskeletal pain have received opioids,8 and about 15% of children with minor conditions received an opioid prescription each year from 1999 to 2014, according to a study of Tennessee children enrolled in Medicaid.9
  • Caucasian children are more commonly prescribed opioids compared to minorities. Most Caucasians had race-concordant providers, while only 34.3% of African American children and 42.7% of Hispanic children had race-concordant providers. Among African American children, having a race-concordant provider was associated with a decreased likelihood of receiving an opioid prescription as compared to having a Caucasian source of care provider.10
  • Adolescent chronic pain has been associated with future opioid misuse.11
  • Adolescents with a range of prior mental health conditions and treatments had substantially higher rates of transitioning from initial opioid receipt to long-term opioid therapy.12
  • On average, more than 3,000 children under the age of 5 suffer from accidental opioid overdose poisoning each year.13 Rates of opioid prescriptions to family members of children and adolescents rose substantially between 1996 and 2012, placing children at greater exposure to opioids in their homes and communities.10

There should be much caution with prescribing opioids in pediatric patients. (Source: 123RF)


The Guidelines

Guidelines for prescribing opioids to children and adolescents are currently suffering from a lack of research and under-representation in the medical literature. The use of long-term opioid therapy in the under-18 population has not been adequately studied, and much is still left unknown. While many states and large children’s hospitals have their own pediatric-specific guidelines for prescribing pain medication (see below), there is less consensus on the national and organizational front.

The American Pain Society (APS) notes: “Opioids are rarely indicated in the long-term treatment of chronic nonmalignant pain in children, although they may be beneficial in certain painful conditions with clearly defined etiologies.”1 The society offers sickle cell disease, incurable degenerative joint, and neurodegenerative diseases as examples.

The CDC’s 2016 guideline on prescribing opioids for chronic pain2 only provides recommendations for patients over age 18. When it comes to children and adolescents, the CDC merely states: “The available evidence concerning the benefits and harms of long-term opioid therapy in children and adolescents is limited, and few opioid medications provide information on the label regarding safety and effectiveness in pediatric patients.” One clear differentiation was made in April 2017, when FDA announced that children younger than age 12 should not take codeine or tramadol.3

The CDC does, however, have observational data showing that opioid prescriptions for pediatric populations grew significantly between 2001 and 2010, much like the trend for adults, and that “a large proportion of adolescents are commonly prescribed opioid pain medications for conditions such as headache and sports injuries.”2 Further, there are known risks related to opioid use in this vulnerable population, including complications that may be experienced later in adulthood (eg, heroin use or comorbid mental health conditions).

As the healthcare community continues to work on how to best address the specific needs and risks of younger patients facing chronic pain, as well as how to safely and effectively manage acute pain after injury or surgery, the following highlights from hospital and state guidelines provide a foundation for clinicians treating children when it comes to opioid therapy and alternatives.

Nationwide Children’s Hospital (Columbus, OH)4

  • Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks.
  • Providers should prescribe short-acting opioids. When opioids are used for acute pain, providers should prescribe the lowest effective dose of short-acting opioids and should prescribe no greater quantity than needed for the expected duration of pain. Incorporate strategies to mitigate risk including mental health concerns, patient or family risk of addiction.
  • Clinicians should review the patient’s history of controlled substance prescriptions to determine whether the patient is receiving excessive opioid dosages or dangerous combinations. Use urine drug testing before starting opioids for chronic pain.
  • Clinicians should prescribe the lowest possible effective dosage. Providers should evaluate patients within 1 to 4 weeks of starting dose escalation to assess benefits and harms of continued opioid therapy. Providers should evaluate patients every 3 months, or more frequently for benefits and harms of continued opioid therapy.

Children’s Hospital Colorado (Aurora, CO)5

  • Providers should proceed with cautious use and prescription of opioid therapy, limiting the amount prescribed while ensuring pain management.
  • No long-acting opioids may be prescribed in the emergency department/urgent care. It is recommended to avoid long-acting opioids in inpatient and surgical settings as well.
  • Clinicians should recommend the use of non-pharmacologic and multimodal approaches to pain management.
  • If pharmacogenomic testing is available or has been completed, it should be considered for all patients.

Pennsylvania State Guidelines6

  • Opioid analgesics should be reserved for those children and adolescents with moderate to severe pain. Children in need of these medications most often are post-
    operative patients and those with sickle cell crisis, cancer, or those receiving palliative or end-of-life care.
  • The opioids of choice when treating children for moderate to severe pain are morphine or oxycodone.
  • Combination medications with set amounts of an opioid paired with a set amount of either acetaminophen or ibuprofen are to be avoided since the dose of one or two medications in the pair is likely to be too low or too high. It is better to prescribe these medications separately.

It is important to note that children are affected by opioids directly but also indirectly. Bipartisan opioid law7 signed by President Trump in October 2018 aims to address the adolescent population affected by family members who may have an Opioid Use Disorder (see more regarding pregnancy and opioid use on page 29). According to the legislation, the US Department of Health and Human Services must begin to provide resources to early childhood care and education providers and other professionals working with young children on how they can “recognize and respond to children” who may be affected by such circumstances. The healthcare community also continues to address the challenge of neonatal abstinence syndrome, and FDA is supporting the development of new children’s medical devices through its Pediatric Device Consortia.


-Reported by Steven Aliano


Last updated on: December 5, 2018
Continue Reading:
Intranasal Ketamine for Acute Pain in Children
close X