Treatment of opioid use disorder
New guidelines can arm pediatricians with the basic understanding of treatment options to manage opioid dependence or addiction in children.
As problems with opioid use and abuse in the United States increasingly emerge to create what is being called a public health epidemic, clinicians are facing the great challenge of trying to provide optimal pain management for their patients while being mindful of the potential deleterious effects of the highly addictive opioids. When used properly, these drugs provide great pain relief, but their easy misuse and abuse create a cascade of problems that has led to current debates on their appropriate and best use for pain management.
Within this larger debate is the difficult issue of how to treat patients who become dependent or addicted to opioids. For pediatricians and other healthcare providers who care for children who develop an opioid dependence or addiction, the challenge to treat this dependence is all the greater given the lack of good guidelines geared particularly for children and adolescents.
Conflicting guidelines for kids
The need for guidance is critical. Prescription of opioids to US children for medical reasons has doubled over the past decade, with the majority of opioids prescribed for postprocedural and postoperative use in children aged between 10 and 17 years.1 In 2009, more than 7 million prescriptions for opioids were dispensed for children. Accompanying this increase in opioid prescriptions are the numbers that tell the problem. According to data from the Centers for Disease Control and Prevention (CDC), nearly 2 million people in the United States aged 12 years and older either abused or became dependent on opioids in 2013.2 In addition, 2.6 of 100,000 persons in the United States aged between 15 and 24 years died from an overdose of prescription opiods.
The recently published 2016 guideline from the CDC on prescribing opioids for chronic pain, which includes a recommendation for evidence-based treatment for opioid use disorder, provides needed guidance for adults, and it explicitly states that the guidelines apply only to patients aged 18 years or older.3 However, as emphasized in an accompanying editorial, pediatricians and primary care providers should take care not to extrapolate from this evidence geared toward adults and tailor it inappropriately, and perhaps with detriment, to children and adolescents.2
In 2014, the American Academy of Pediatrics (AAP) published a clinical report on management strategies for weaning children and adolescents off opioids (at the same time emphasizing the lack of clear evidence on a single ideal protocol). Highlighted is the need for gradual dose reduction without abrupt drug discontinuation.1 Although no management strategies were provided for how to treat children and adolescents who become dependent on or addicted to opioids, the clinical report does reference data from treatment programs for adolescents who are dependent on prescription opioids or heroin that include behavioral intervention in their treatment programs. (For the description of an attempt by a US tertiary care children’s hospital to standardize management of iatrogenically induced opioid dependence and withdrawal, see “Treatment of opioid dependence: Protocol developed at a tertiary care children’s hospital”)