Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

ABSTRACT

Introduction

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child’s chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

Areas covered

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child’s severe surgical pain. Research suggests that ‘older’ and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

Expert opinion

The opioid and analgesic pharmacogenomics approach can proactively ‘tailor’ a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic’s socioeconomic, personal, and psychological strains globally.

KEYWORDS:

• Opioid addition
• opioid use disorder
• methadone
• opioids
• pain
• pediatric
• postoperative pain
• chronic persistent surgical pain

Article highlights

• Opioids are used for post-surgical pain, yet children still suffer from severe pain and numerous adverse effects of opioids.

• There are many risk factors that predispose a child, especially an adolescent, to opioid use disorder including medical, psychological, socioeconomic, age of first opioid exposure, genetics and environment.

• Methadone, an old long-acting opioid and an opioid-sparing opioid, is showing new promise toward decreasing chronic post-surgical pain.

• New research is uncovering the effects that a patient’s genetic composition, glycoprotein variations, and CYP2D6 polymorphisms have on the efficacy and adverse effects of opioids. As our understanding of pharmacogenomics grows, the ability to individualize perioperative analgesia has the potential to transform pain medicine.

Declaration of interest

S Sadhasivam has received NIH funding: R01HD089458 (PI: S Sadhasivam), R21HD094311(PI: S Sadhasivam), R01HD096800 (PI: S Sadhasivam), R44DA055407, R44DA056280, R41DA053877 (MPI: S Sadhasivam), R01DA054513 (MPI: Chelly/S Sadhasivam), R01DA059321 (PI; Radhakrishnan) and U01TR003719 (PI: S Sadhasivam). S Sadhasivam received pay from UpToDate: Anesthesia for Tonsillectomy and Neuroptics, Inc for studying opioid-induced respiratory depression in pediatric tonsillectomy. S Sadhasivam is one of the inventors in the approved U.S. patents focused on opioid pharmacogenetics: U.S. Patent No. 9944985, 10662476, 16/850537, 16/946401, 16/946399, 10878939. He is the founder and chief medical officer of OpalGenix, Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Two reviewers received an honorarium from Expert Review of Clinical Pharmacology for their review work but have no other relevant financial relationships to disclose.

Author contributions

All authors conceived the question, wrote the manuscript, and approved the final manuscript.

Additional information

Funding

This paper was not funded.