An expert panel has issued new guidelines for prescribing postsurgical opioids to children and adolescents in an effort to prevent misuse of the drugs.
In an opinion paper published in JAMA Surgery, the experts noted that “evidence-based guidelines for opioid prescribing practices in children are lacking.” The experts reviewed research spanning more than 30 years on opioid use and risks in children and adolescents under age 18. They then created the new guidelines, which were “reviewed, edited, and endorsed externally” by pediatric surgical specialists — the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee and the American College of Surgeons Board of Regents.
The guidelines have three main suggestions: first, that “health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids,” noting the panel’s review found that opioid misuse occurs “frequently, particularly for adolescents with access to opioids.” Second, non-opioid pain medications should be “optimized” and were found to be “effective to minimize or eliminate the need for opioids after surgery.” Lastly, the guidelines highlighted the need to educate young patients undergoing surgery and their families about pain management before and after the procedure.
Dr. Alan Schroeder, critical care physician at Stanford Children’s Health, who was not part of the panel, tells Yahoo Life that the new guidelines are an “excellent synopsis of the scope of the problem and the necessary next steps. I hope that there is immediate and widespread uptake of these guidelines.”
Weighing opioid risks
Opioids are powerful medications that help with pain management, but they’re not without risks. “Opioids can lead to dependence or misuse, especially in adolescents, including increasing risk of future IV drug abuse,” Dr. Bindi Naik-Mathuria, associate professor in the Michael E. DeBakey department of surgery at Baylor College of Medicine and a member of the department of surgery at Texas Children’s Hospital, tells Yahoo Life. “They can also have adverse events, such as oversedation.”
Schroeder adds that opioids have “consistently been demonstrated to be associated with subsequent use and abuse” and says, “They tend to be overprescribed and the unused pills get used recreationally by the patient and/or diverted to friends and families. Additionally, the pills may get accidentally consumed by young children and toddlers.”
Although the guidelines are meant to address and reduce the risk of opioid overuse in children and adolescents, some experts say the risk is “overstated,” while others have expressed concern that the guidelines may “discourage the appropriate use of opioids, though I know that wasn’t the intent of the authors,” Dr. Elliot Krane, the chief of pediatric pain management at Stanford Children’s Health, who was not involved in the guidelines, told the New York Times.
Schroeder understands the concerns about potentially discouraging appropriate opioid use, but he says, “The authors’ suggestions for non-opioid pharmacological approaches and regional anesthesia should mitigate many of these concerns.”
One of the authors of the guidelines, Dr. Lorraine Kelley-Quon, a pediatric surgeon at Children’s Hospital Los Angeles, tells Yahoo Life: “Just like adults, children may need to undergo painful operations, and prescription opioids may be part of helping them reach full recovery. Our guidelines stress that recognition of the risks associated with prescription opioids is necessary, that there is evidence for effective non-opioid therapies for children and teens that can minimize or eliminate the need for opioids after surgery and that education of families both before and after surgery is paramount.”
What to ask your child’s doctor about opioids
So what can parents and doctors do to ensure that children and adolescents are using these pain medications safely and correctly?
First, Schroeder suggests finding out if the surgery is truly needed, noting that one way to reduce opioid exposure is to “avoid procedures that are potentially unnecessary.” For example, third molar (“wisdom teeth”) extractions are “one of the biggest drivers of opioid prescriptions in adolescents and young adults,” Schroeder says. “We can try to limit opioids when this surgery is performed, but we also need a better understanding of whether the procedure should, in fact, be performed so commonly.”
However, if surgery is required, it’s important that families “have a conversation with their surgeon preoperatively about pain management after surgery and whether opioids will be prescribed,” says Kelley-Quon.
Experts — including Schroeder and Sharon Wrona, director of comprehensive pain and palliative care services at Nationwide Children’s Hospital — recommend asking your child’s doctor whether there are safe alternatives to opioids that can help reduce postoperative pain. Wrona tells Yahoo Life that some providers aren’t recommending and some families aren’t understanding that over-the-counter medications can help with pain management. Instead, they may be “only using [opioids] and not using a multimodal approach,” Wrona says. “That’s not the best way to manage pain.”
“Speaking from personal experience, once surgeons can see for themselves that their patients do just as well with non-opioid pain regimens after certain types of surgery, it becomes easier to understand,” says Naik-Mathuria. “If the alternatives don’t work after a trial period, then opioids can still be prescribed as a backup plan.”
Before prescribing opioids, Wrona says that doctors need to have a conversation with their adolescent patients and their families about prescription drug misuse, as well as any family or personal risk factors, such as drug use or abuse and mental health issues. “A patients’ history of addiction can put them at risk for abuse of opioids,” says Wrona. “Unless you ask about that family or personal history, then you don’t even know if there is a risk.”
Schroeder also recommends questioning “whether they really need 20 to 30” pills — the amount that’s commonly dispensed in a prescription, according to Schroeder.
Naik-Mathuria agrees that limiting the number of pills prescribed is also “an important safety plan,” adding: “For example, prescribing five pills to use for severe pain when non-opioids fail versus 20 pills that you may have routinely prescribed ‘just in case’ they were needed.”
Families also need to be educated about “appropriate use, storage and disposal both before and after surgery,” says Kelley-Quon. Wrona recommends storing opioids in a locked box that children and adolescents, as well as pets, cannot access. She also suggests monitoring how many opioids you have on hand and keeping track of how many you have given your child or adolescent “so you know if you’re missing five,” adding, “Kids can find it and experiment.”
According to Nationwide Children’s Hospital, eight out of 10 adolescents who report misusing prescription opioids say they got the drugs from “leftover prescriptions from friends and family members.” That’s why Wrona says doctors need to let patients and their families know how to safely dispose of any unused medications, such as flushing them down the toilet only if the prescription is listed on the FDA’s flush list, or dropping off the medications at a drug take-back site (you can find them here).
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