Appropriateness of opioid prescriptions in children: the elephant in the room – Reply

We read with interest Wiel et al’s commentary and thank them for highlighting an important point regarding our research on opioid prescribing practices in youth.¹ The authors comment on the importance of opioid prescribing in certain settings, while also emphasizing avoidance of opioids when alternative pain management options are present. We agree that opioid prescribing must be evidence-based, with recognition that opioids are appropriate treatment for children with specific conditions (particularly severe acute pain, certain chronic diseases, such as cancer, and palliative care), but that this should be counterbalanced with an understanding of potential opioid-related risks, including side effects, intentional or unintentional overdose, and future opioid use disorder.

In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines on opioid prescribing for chronic pain with a focus on adults.² Subsequent research has demonstrated that these guidelines may have decreased opioid prescribing and certain high-risk prescribing practices in adults.³ Conversely, these guidelines may have had unintended consequences, such as leading clinicians to conduct rapid opioid tapers that have been linked to adverse outcomes, such as worsening of pain, and anxiety, depression, and suicide.⁴ While the CDC guidelines may have had an impact on pediatric opioid prescribing—as shown in our study, which demonstrated decreasing trends in overall opioid prescriptions in youth and certain high-risk practices in adolescents—these guidelines were not intended for patients less than 18 years old. To ensure appropriate opioid prescribing for youth across all settings, national evidence-based pediatric- and adolescent-specific clinical practice guidelines are necessary to provide standardized clinician guidance for the treatment of both acute and chronic pain in this population. The publication of pediatric postoperative opioid prescribing guidelines earlier this year represents an important step in moving toward general opioid prescribing guidelines for youth.⁵

Our study highlights current trends in opioid prescribing practices in youth based on age, with notable differences in trends by age group for potential high-risk prescribing practices. While we were limited in determining the appropriateness of each opioid prescription in our study, our findings of increasing rates of high-dosage, long-duration, and extended-release or long-acting formulation prescriptions in young children warrants further study. Prescription opioids are implicated in a large percentage of opioid overdoses among youth and opioids remain readily dispensed.⁶ Pediatric- and adolescent-specific opioid research and targeted interventions must be prioritized in order to prevent opioid-related morbidity and mortality within this population.