New Guidelines Cover Opioid Use After Children’s Surgery

Opioids are very effective drugs for managing pain, but they can also be scary drugs, with their potential for misuse and abuse. Given the current opioid epidemic in the United States, some parents worry about whether they are safe for children, while many pain experts worry that fear of opioids among parents and among physicians may contribute to the undertreatment of pediatric pain.

In new guidelines published in November in the journal JAMA Surgery, a panel convened by the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee set out some guidelines for how to think about — and prescribe — opioids for children to relieve pain after surgery. “It’s important to understand that children undergo a lot of painful procedures,” said Dr. Lorraine Kelley-Quon, a pediatric surgeon at Children’s Hospital Los Angeles, who was the lead author on the guidelines. “They have real pain; opioids can help.”

Matthew Kirkpatrick, an addiction expert who is an assistant professor in the department of preventive medicine at the Keck School of Medicine at the University of Southern California, and who was one of the authors of the new guidelines, said, “We don’t want to contribute to scaring parents and to scaring physicians about undertreating pain.” From the data they reviewed, he said, “kids that use these medications as prescribed are at very low risk for abuse and dependence either in the short term or the long term.”

However, the first six statements in the guidelines discuss the risks of adolescents misusing prescription opioids (misuse is anything other than use exactly as directed by the prescriber, or use without a prescription), diverting them (giving them away or selling them), and possibly having a higher risk of problems with opioids in the future. Dr. Kelley-Quon pointed out that many health care practitioners may not be familiar with the addiction literature. But some pain experts warn that heavy emphasis on that risk as a way of framing the issue may frighten both parents and doctors.

Dr. Elliot Krane, the chief of pediatric pain management at Stanford Children’s Health, who was not an author of the new guidelines, said, “the concern is that the paper is going to discourage the appropriate use of opioids, though I know that wasn’t the intent of the authors — the reason I think that’s the risk is they set up their recommendations with a premise which I think is untrue, that kids are dying and becoming addicts” at an increasing rate.

Dr. Krane disputed some of the statements about the risk: “I think the evidence that opioid abuse is increasing in children is very weak; I think the evidence in children that prescription opioids lead to later abuse isn’t there at all.”

Dr. Scott Hadland, a pediatrician and addiction specialist at Boston Medical Center, who was not involved with the guidelines, said, “While I agree with the recommendations, I agree also with the concern from the pain community that risk may be overstated — may not be as large as some of the earlier studies have suggested.”

The guidelines recommend non-opioid medications as first-line postoperative drugs, including the use of regional anesthesia.

But when opioids are used, the guidelines stress careful supervision. “It all boils down to access,” Dr. Kirkpatrick said, and the imperative is to make sure that parents and physicians get the right information “to manage the dispensing of the medication to their kids and the access that their kids have to the medication.” Parents should not be afraid of managing the child’s pain with opioids when they are needed, but should understand the importance of controlling that access in children and through adolescence.

“The parent should be highly engaged in managing the child’s pain, in making sure the child gets the medication to manage the pain, but the child does not have access to the drug on their own.”

Dr. Kirkpatrick said that overprescribing by physicians has contributed to opioid use and misuse in adults. In data from a national survey on drug use and health, he said, kids were most likely to get medication they had misused from friends or family members, but when they were asked where that person had gotten it, it was often from a doctor.

Dr. William Zempsky, the division head of pain and palliative medicine at Connecticut Children’s Medical Center, who was not an author of the guidelines, said that while opioids have been prescribed inappropriately to adults in some settings, there is no clear evidence that it has been a problem in pediatrics.

“We need to do things right, but we don’t need to scare people,” Dr. Zempsky said. “Kids continually are at risk for lack of appropriate postoperative surgical management because of fear of opioid addiction.”

Dr. Eugene Kim, the chief of the division of pain medicine at Children’s Hospital Los Angeles, who was one of the authors of the guidelines, said, “I am aware of the caution that certain pain management experts have,” regarding the dangers of underprescribing and undertreating pain. The guidelines should be the basis for ongoing conversations, he said, as well as for responsible prescribing.

“Parents of children who are undergoing surgeries should be educated as to when to use the medications, how to use the medications, and we, as providers, should be involved in that process from the get-go as far as the education process, as far as responsible prescribing, as far as follow up.”

Some adolescents may be particularly at risk for problems with opioids, especially those who have had substance use problems in the past, and those who have mental health problems.

With patients at higher risk, Dr. Hadland said, such as those with anxiety or depression or those who have had substance abuse issues, opioids can still be prescribed when they’re needed, but “we should take great care.”

When a patient of his, a young adult who had alcohol use disorder, needed surgery, Dr. Hadland said, “I and the patient themselves were both concerned about the potential misuse of opioids because of the history of addiction.” He and the surgeon partnered, he said, and agreed that Dr. Hadland would do the postoperative pain management because he was more readily available and more comfortable working with a patient who had this history. He prescribed very small amounts of oxycodone, he said, discussing at every stage with the patient how it felt to be taking the medication. “We had open communication around it and things went really well.”

The guidelines go beyond the discussion of when opioids should be used and cover the importance of educating both children and their parents and caregivers about the possible side effects of opioids (oversedation and respiratory depression), about the importance of following medical instructions carefully, about the need for storing these medications securely (that is, in a locked area) and getting any unused doses out of the home in a safe and secure way (they should be returned to a secure opioid disposal bin).

None of the other specialists I spoke with suggested changing the specific recommendations for multimodal pain relief, for using opioids when other drugs are insufficient for effective pain control, and for good parent education leading to careful oversight, locked storage and safe disposal of unused doses.

“The spirit behind these guidelines is correct,” Dr. Hadland said. “Prescribing the lowest effective dose for the shortest period of time, use only short acting formulations, and talk to families about risks and monitoring dosing and locking up medication.”

Parents and physicians can feel safe that if kids are using these medications as prescribed to manage their pain, Dr. Kirkpatrick said, they are “not at significantly greater risk for developing opioid use related problems.”

“If your child needs surgery, talk to your doctor, ask questions about what pain should be expected,” Dr. Kelley-Quon said. Ask if opioids will be used, and if so, how should they be used, and how can they be safely disposed of, she said. “We want to be at the sweet spot, treating pain appropriately, maximizing benefit and minimizing risk.”

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