An update on the safety of prescribing opioids in pediatrics

ABSTRACT

Introduction: The opioid abuse epidemic and its toll on the adolescent population have heightened awareness for safer opioid prescribing practices in pediatric pain management. Opioids remain the mainstay of therapy for severe pain, although there is an emphasis on multimodal therapy.

Areas covered: In this update, the authors present information on parenteral/oral opioids commonly used in pediatrics. Recommendations for opioid use in special circumstances including neonates and developmental pharmacokinetic concerns are discussed. Due to noticeable interindividual variability, pharmacogenomics may be important for tailoring pain regimens. In particular, the role of CYP2D6 phenotypes on opioid selection/dosing and clinical implications are discussed. A summary of adverse effects and opioid safety data, and the role of regulations, risk assessment, Centers for Disease Control and Prevention guidelines, follow-up, and monitoring for compliance in opioid prescribing, are detailed.

Expert opinion: ‘One size does not fit all’ describes the need for public policies focused on pediatric pain and opioid use, as children are not ‘little adults.’ Clinical trials to evaluate pharmacokinetics–pharmacodynamics of opioids are currently lacking. Development of novel biased opioid agonists, clinical integration of genetics in informed decision-making, and emphasis on top-down approaches to pain management will be key to decrease opioid reliance.

KEYWORDS:

• Opioid
• pediatric
• dosing
• guidelines
• pain management
• prescribing

Article highlights

• Opioid prescribing rates, opioid misuse, and mortality from opioid abuse are on the rise in adolescents, which makes careful prescribing of opioids an important responsibility of all health-care providers.

• The authors provide information for the safe use of commonly used parenteral and oral opioids in the pediatric population.

• The authors discuss opioid use in special populations, including neonates, and other systemic conditions like obesity and renal failure which influence the metabolism and effects of opioids.

• The authors review the importance of pharmacogenomics on opioid selection and dosing, with a special emphasis on CYP2D6 implications for opioid dosing, and warnings against use of codeine in the pediatric population

• The role of regulations, risk assessment, follow-up, and monitoring for compliance in opioid prescribing has been discussed in detail with an overview of authors’ practices as a guideline.

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Declaration of interest

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This project was supported by the 5K23HD082782 through the Eunice Kennedy Shriver National Institute Of Child Health & Human Development, National Institutes of Health.