CLINICAL PRACTICE GUIDELINE Guidance for the Clinician in Rendering Pediatric Care
Opioid Prescribing for Acute Pain
Management in Children and
Adolescents in Outpatient Settings:
Clinical Practice Guideline
Scott E. Hadland, MD, MPH, MS, FAAP,a Rita Agarwal, MD, FAAP, FASA,b Sudha R. Raman, PhD,c Michael J. Smith, MD, MSCE,d
Amy Bryl, MD, FAAP,e Jeremy Michel, MD, MHS, FAAP,f Lorraine I. Kelley-Quon, MD, MSHS, FACS, FAAP,g
Mehul V. Raval, MD, MS, FAAP,h Madeline H. Renny, MD, MS, FAAP,i Beth Larson-Steckler,j Scott Wexelblatt, MD, FAAP,k
Robert T. Wilder, MD, PhD, FAAP,l Susan K. Flinn, MAm
This is the first clinical practice guideline (CPG) from the American
abstract
a
Academy of Pediatrics outlining evidence-based approaches to safely Mass General for Children; Harvard Medical School, Boston,
Massachusetts; bStanford University School of Medicine, Stanford,
prescribing opioids for acute pain in outpatient settings. The central California; Departments of cPopulation Health Sciences and dPediatrics,
goal is to aid clinicians in understanding when opioids may be indicated Duke University School of Medicine, Durham, North Carolina; eDivision of
Emergency Medicine, Rady Children’s Hospital San Diego and
to treat acute pain in children and adolescents and how to minimize Department of Pediatrics, University of California San Diego, San Diego,
risks (including opioid use disorder, poisoning, and overdose). The California; fDepartment of Pediatrics, Perelman School of Medicine,
University of Pennsylvania and Department of Biomedical Informatics,
document also seeks to alleviate disparate pain treatment of Black, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; gDivision
Hispanic, and American Indian/Alaska Native children and adolescents, of Pediatric Surgery, Children’s Hospital Los Angeles and Departments of
Surgery and Population and Public Health Sciences, Keck School of
who receive pain management that is less adequate and less timely
Medicine, University of Southern California, Los Angeles, California;
than that provided to white individuals. There may also be disparities h
Division of Pediatric Surgery, Department of Surgery, Northwestern
in pain treatment based on language, socioeconomic status, geographic University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, Illinois; iDepartments of Emergency
location, and other factors, which are discussed. Medicine, Pediatrics, and Population Health Science and Policy, Icahn
School of Medicine at Mount Sinai, New York, New York; jChildhood
The document recommends that clinicians treat acute pain using a Pancreatitis Foundation, Minot, North Dakota; kDepartment of Pediatrics,
multimodal approach that includes the appropriate use of University of Cincinnati College of Medicine, Cincinnati Children’s Hospital
Medical Center Perinatal Institute, Cincinnati, Ohio; lMayo Clinic Alix
nonpharmacologic therapies, nonopioid medications, and, when needed, School of Medicine, Rochester, Minnesota; and mMedical Writer
opioid medications. Opioids should not be prescribed as monotherapy
This document is copyrighted and is property of the American
for children or adolescents who have acute pain. When using opioids for Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy of
acute pain management, clinicians should prescribe immediate-release Pediatrics. Any conflicts have been resolved through a process
opioid formulations, start with the lowest age- and weight-appropriate approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
doses, and provide an initial supply of 5 or fewer days, unless the pain is involvement in the development of the content of this publication.
related to trauma or surgery with expected duration of pain longer than
5 days. Clinicians should not prescribe codeine or tramadol for patients
younger than 12 years; adolescents 12 to 18 years of age who have To cite: Hadland SE, Agarwal R, Raman SR, et al. American
Academy of Pediatrics. Opioid Prescribing for Acute Pain
obesity, obstructive sleep apnea, or severe lung disease; to treat Management in Children and Adolescents in Outpatient
postsurgical pain after tonsillectomy or adenoidectomy in patients Settings: Clinical Practice Guideline. Pediatrics. 2024;154(5):
younger than 18 years; or for any breastfeeding patient. e2024068752
PEDIATRICS Volume 154, number 5, November 2024:e2024068752 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from http://publications.aap.org/pediatrics/article-pdf/doi/10.1542/peds.2024-068752/1713005/peds.2024-068752.pdf
by guest
on 01 October 2024
, The CPG recommends providing opioids when appropriate for treating acutely worsened pain in children and
adolescents who have a history of chronic pain; clinicians should partner with other opioid-prescribing clinicians
involved in the patient’s care and/or a specialist in chronic pain or palliative care to determine an appropriate
treatment plan. Caution should be used when treating acute pain in those who are taking sedating medications. The
CPG describes potential harms of discontinuing or rapidly tapering opioids in individuals who have been on stable,
long-term opioids to treat chronic pain.
The guideline also recommends providing naloxone and information on naloxone, safe storage and disposal of
opioids, and direct observation of medication administration. Clinicians are encouraged to help caregivers develop a
plan for safe disposal. The CPG contains 12 key action statements based on evidence from randomized controlled
trials, high-quality observational studies, and, when studies are lacking or could not feasibly or ethically be
conducted, from expert opinion. Each key action statement includes a level of evidence, the benefit-harm
relationship, and the strength of recommendation.
I. GREETING I wanted to be part of this subcommittee’s work to en-
This is the first American Academy of Pediatrics (AAP) sure inclusion of the perspectives of those with lived expe-
clinical practice guideline (CPG) on opioid prescribing in riences, and my initial hesitancy to take part was due, in
children and adolescents. CPGs provide recommenda- part, to worries about tokenism. Although intentions to in-
tions to improve patients’ care and health outcomes. The clude patients and caregivers are often well-meaning, too
process of the AAP for developing these guidelines is me- often, people with lived experience are only symbolically
ticulous and time intensive. CPG development involves a invited and neither fully valued nor truly immersed in the
thorough review of relevant research and close examina- work. As a caregiver and advocate, I am often critical of
tion of the strength of the studies and other identified how the work of medical organizations impacts patients
documents. The process also considers the benefits and and their families. After witnessing the subcommittee mem-
risks of specific practices. bers’ work and being genuinely engaged and centered in
CPGs have traditionally been developed by physicians the CPG development process, I now have immense respect
and researchers, long viewed as the experts in clinical for the process and every member of the subcommittee.
care. Only recently have caregivers and patients been in- The subcommittee leaders demonstrated thoughtful,
corporated into this process. Many professional organiza- dedicated, and compassionate guidance. They ensured in-
tions seek the involvement of caregivers and patients in clusivity of all voices and encouraged questions and re-
their work; however, it can be challenging to determine spectful debate throughout every conversation. They did
how best to engage families, draw on their perspectives not shy away from hard discussions. They consistently
and experiences, and authentically involve them in the sought to understand how scenarios might impact children
process. Nonetheless, this task is critical: studies have and families and committed to authentically and meaning-
shown that involving patients and caregivers improves fully engaging those with lived experiences. I am grateful
guidelines.1–4 to this group and feel immense comfort that these are the
The involvement of caregivers and patients can help leaders in caring for our children and youth.
identify areas that are important to those with lived ex- The responsibilities of this subcommittee were sub-
periences, highlight real-world barriers to care, increase stantial. As a result of previous misapplications of other
the legitimacy and trustworthiness of the guideline, im- pain management guidelines, there is intense scrutiny on
prove adherence to clinical recommendations, and dis- the issue of opioid prescribing nationally. Various inter-
seminate guidelines to communities of interest. ested groups—including patients, caregivers, government
When I was initially approached about participating in entities, politicians, special interest groups, and advo-
this AAP subcommittee, I was both excited and hesitant. cates—are all presently weighing in on this subject. I knew
I am a caregiver and care partner. Like many, I am an ac- that the subcommittee and our work would be examined by
cidental health care advocate because of my family’s ex- all these stakeholders.
perience with pediatric pain. My advocacy has spanned The subcommittee members hold varied expertise re-
23 years; caring for patients’ pain and access to appro- lated to opioids and represented a broad perspective of
priate opioid prescribing have been a large focus of my views related to prescribing. Subcommittee members re-
advocacy. I have witnessed the misapplication of pain spectfully challenged each other, presented concerns, and
treatment guidelines and the unintended harms that fam- engaged in fruitful debates that were grounded in the
ilies experienced. singular focus to improve care of children and families, all
2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from http://publications.aap.org/pediatrics/article-pdf/doi/10.1542/peds.2024-068752/1713005/peds.2024-068752.pdf
by guest
on 01 October 2024
, Key Action Statement Table
Evidence Recommendation
Key Action Statement (KAS) Quality Strength
KAS 1: Pediatricians and other pediatric health care providers (PHCPs) should treat acute pain using a multimodal B Strong recommendation
approach that includes the appropriate use of nonpharmacologic therapies, nonopioid medications, and, when
needed, opioid medications.
KAS 2: Pediatricians and other PHCPs should NOT prescribe opioids as monotherapy for children and adolescents B Strong recommendation
who have acute pain.
KAS 3: When prescribing opioids for acute pain in children and adolescents, PHCPs should provide immediate- C Recommendation
release opioid formulations, start with the lowest age- and weight-appropriate doses, and provide an initial
supply of
5 days or fewer, unless the pain is related to trauma or surgery with an expected duration of pain of more than
5 days.
KAS 4.1: When treating acute pain in children and adolescents younger than 12 years, pediatricians and other X Strong recommendation
PHCPs should NOT prescribe codeine or tramadol.
KAS 4.2: When treating acute pain in adolescents 12–18 years of age who have obesity, obstructive sleep apnea, or X Strong recommendation
severe lung disease, pediatricians and other PHCPs should NOT prescribe codeine or tramadol.
KAS 4.3: When treating postsurgical pain after tonsillectomy or adenoidectomy in children and adolescents younger X Strong recommendation
than 18 years, pediatricians and other PHCPs should NOT prescribe codeine or tramadol.
KAS 4.4: When treating acute pain in people of any age who are breastfeeding, pediatricians and other PHCPS X Strong recommendation
should NOT prescribe codeine or tramadol.
KAS 5: When treating acute pain in children or adolescents who are taking sedating medications, such as X Strong recommendation
benzodiazepines, pediatricians and other PHCPs should use caution when prescribing opioids.
KAS 6: When prescribing opioids, pediatricians and other PHCPs should provide naloxone and counsel patients and X Recommendation
families on the signs of opioid overdose and on how to respond to an overdose.
KAS 7: When prescribing opioids, pediatricians and other PHCPs should educate caregivers about safe storage and D Option
directly observed administration of medications to children and adolescents.
KAS 8: When prescribing opioids, pediatricians and other PHCPs should educate caregivers about safe disposal of A Strong recommendation
unused medications, help caregivers develop a plan to safely dispose of unused medications, and, if possible,
offer safe disposal in their practice setting.
KAS 9: When treating acute, worsened pain in children and adolescents with preexisting chronic pain, pediatricians D Option
and other PHCPs should prescribe opioids when indicated and partner with any other opioid-prescribing
clinicians involved in the patient’s care and with specialists in chronic pain, palliative care, and/or other opioid
stewardship programs to determine an appropriate treatment plan.
A: Well-designed randomized controlled trials (RCTs) or diagnostic studies on relevant population.
B: RCTs or diagnostic studies with minor limitations, overwhelmingly consistent evidence from observational studies.
C: Observational studies (case-control and cohort design).
D: Expert opinion, case reports, reasoning from first principles.
X: Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit or harm.
while minimizing risk. The members’ commitment, care, II. BACKGROUND
and compassion were evident in every discussion the Pain is among the most common symptoms that prompt
group engaged in. The discussion of the benefits and risks children, adolescents, and families to present for medical
was nuanced, carefully examining various aspects to en- care.5–7 As a medication class, opioids have long had a
sure that children would not suffer under the misapplica- beneficial role in the management of some pediatric pa-
tion of guidelines, as has happened to adults with pain. tients’ pain, particularly when that pain is severe. Since
It is with gratitude and respect that the first AAP clini- the turn of the century, however, rates of opioid use dis-
cal practice guideline on opioids prescribing in children order (OUD), poisoning, and overdose have increased
and adolescents is introduced. The development of this dramatically among children and adolescents in the
CPG not only adhered to all necessary criteria but also United States.8–15 Rates of pediatric opioid prescribing
stemmed from the subcommittee’s desire and commit- have decreased since a peak in the early 2010s.14–16
ment to improve care for all children and families by Against the backdrop of a worsening national opioid-
merging the best clinical recommendations with the hu- related overdose crisis, some might interpret this change
man aspects of lived experience. as a positive one. Yet, this widespread decrease in opioid
With great admiration and appreciation, prescribing to pediatric patients likely includes reduc-
Beth Larson-Steckler tions not only in inappropriate but also in appropriate
Care partner, advocate, Co-Founder Childhood Pancreatitis opioid use to treat severe pain that is not fully respon-
Foundation sive to other interventions.17–19
PEDIATRICS Volume 154, number 5, November 2024 3
Downloaded from http://publications.aap.org/pediatrics/article-pdf/doi/10.1542/peds.2024-068752/1713005/peds.2024-068752.pdf
by guest
on 01 October 2024
