Last year a committee of excellent and dedicated pediatricians put out pediatric opioid prescribing guidelines. The response was enthusiastic, supportive, and sadly uninformed.
The guidelines recommend no more than 5-day prescriptions. The data actually shows the risk of opioid misuse begins after 3 days. Furthermore, the guideline doesn’t address the other predictors: potency and formulation. The guideline also allows for leeway for surgeons to prescribe longer. As pediatric surgeons first train as general surgeons, their biases are build on longer and less bother.
Most concerning, the guidelines reveal a persistent misunderstanding from the Sackler/Purdue days: opioids do not cure pain, they are no better than over-the-counter options, and pain-free is not a reasonable goal. Beyond this, the understanding of reward-deficient genetics predisposing to abuse is completely ignored. Regardless of surgery, an average of 5% who are given opioids then develop opioid use disorder. Children are even more susceptible, with multiple studies correlating prior medical opioids with a greater risk of misuse.
While the guidelines tell doctors to use multimodal pain relief as first line, we don't get much education on this. Pharma-forward training means many will substitute gabapentin rather than making a pain plan, using physical, supplemental, and brain-body interventions. This is asking for lawsuits.
After a decade of attending anesthesia conferences and sitting in NIDA scientific review groups, I believe pediatricians simply underestimate the risks of opioids compared to our adult and anesthesia colleagues.
If your hospital doesn’t offer, encourage, or understand multimodal pain management, please watch my TED talk, then find our What Works for Pain book. And let your Quality and Risk officers know.