Wean kids off opioids carefully: guideline

By Will Boggs MD

NEW YORK (Reuters Health) - Children can develop opioid dependence after just seven days and can experience withdrawal on abrupt discontinuation of treatment. Now, for the first time, there's a guideline that addresses how to recognize and manage this situation.

Doctors who prescribe opioids should be aware of the potential for dependence, Dr. Jeffrey L. Galinkin from University of Colorado in Aurora told Reuters Health by email. "They should also be able to treat the problems that occur as a result of these drugs and should not pawn this off on subspecialists such as pediatric pain providers who are in very short supply and have very long wait lists to be seen."

He also said prescribing doctors need to warn patients and families appropriately.

Guidance on this subject is available only for adults and, even there, mainly for adults with substance use disorders, although there is a guideline specifically for managing opioid withdrawal in newborns.

In response, the American Academy of Pediatrics' Committee on Drugs and Section on Anesthesiology and Pain Medicine convened to summarize existing literature and provide information not currently available in any single source for the pediatric population.

Dr. Galinkin, Dr. Jeffrey Lee Koh from the University of Chicago, and colleagues point out in the guideline, published online December 30 in Pediatrics, that more than seven million outpatient opioid prescriptions were dispensed in 2009 for children in the U.S. The vast majority were for children between the ages of 10 and 17.

Withdrawal can occur not only when opioid administration is abruptly decreased or discontinued, but also when an alteration in gastrointestinal absorption leads to decreased absorption or with a transition from IV to oral administration.

In children, behavioral changes (anxiety, agitation, insomnia, and tremors) often precede physiologic changes (increased muscle tone, nausea, vomiting, diarrhea, decreased appetite, tachypnea, tachycardia, fever, sweating, and hypertension), according to the guideline.

The guideline says prevention of withdrawal is the favored management strategy, and this requires weaning for patients exposed to an opioid for longer than 14 days and even for some patients with shorter opioid exposure.

Rescue opioids should be offered when withdrawal symptoms develop during weaning, but whether to use off-label adjunctive medications in this population remains controversial, and there is little information to provide guidance on their use.

The guideline mentions several tools for monitoring children undergoing opioid withdrawal. Consistent use of such instruments is vital to detecting early signs of withdrawal so a treatment strategy can be implemented, they say.

The guideline says that only the Sophia Observation Withdrawal Symptoms Scale (SOWS) has been validated. However, Dr. Linda S. Franck from the University of California, San Francisco, who has researched opioid withdrawal in children, pointed out in email to Reuters Health that SOWS is not the only validated pediatric withdrawal assessment scale.

"The Withdrawal Assessment Tool (WAT)-1 was the first and most widely used validated pediatric withdrawal assessment tool, but it is not cited in the paper," she said. "In fact, the WAT-1 is the withdrawal assessment tool used in the largest trial ever of an analgesia and sedation protocol in children - the NIH funded RESTORE Trial of Sedation Management in Pediatric Patients with Acute Respiratory Failure (U01 HL086622 and U01 HL086649), which just completed enrolment this year."

The report also recommends the use of behavioral interventions to help with sleep, anxiety/mood symptoms, and pain-related symptoms that can occur during weaning.

What else might be done to manage these children?

"The first is to give these drugs at appropriate times," Dr. Galinkin said. "Opioids are often a knee jerk reaction for many procedures and for pain management. This should not be the case. Giving an opioid to treat pain should be (part of) a well thought out plan and only used if a patient will require use. These days there are many potent options for pain management which may have lower risks then opioids such as non-steroidals, novel mu-1 agonists such as tramadol, and regional blocks and continuous local anesthetic catheters that can minimize post procedure and acute painful injury pain."

"Most people do not realize the negative consequences of stopping an opioid abruptly," Dr. Galinkin said. "It is critical that practitioners appropriately coach families and provide adequate information about the consequences of abrupt withdrawal when prescribing opioids for mid- and long term use."

"Unfortunately," he added, "opioid diversion and abuse is a growing issue in the US among teens. In disposing of opioids, practitioners who prescribe these drugs should also tell patients appropriate ways to dispose of these drugs following local guidance."

He pointed out that guidance for disposal can be found here: www.fda.gov/forconsumers/consumerupdates/ucm101653.htm.

Dr. Deborah Fisher, Clinical Director of Pediatric Palliative Care & Pain Management at Children's Hospital of Richmond, Virginia told Reuters Health by email, "Use of validated pain assessment tools with weight-based, opioid dosing based on level of pain can decrease overall opioid exposure. Use of appropriate weight-based dosing can assist in achieving analgesia in a timely manner, thus potentially decreasing length or opioid exposure."

"All infants, children, adolescents, and young adults who have received opioid therapy for five or more days should have an assessment based opioid weaning plan developed," Dr. Fisher advises. "Ideally, guidance may be provided by either a Pediatric Palliative Care provider or a PharmD with expertise in opioid management."

Dr. Franck says weaning children from opioids requires a team approach.

She told Reuters Health by email, "Nurses are responsible for assessment of withdrawal symptoms, pain and sedation using validated measures and best practice guidelines; parents and older children can taught by nurses how to assist in monitoring symptoms and treatment response; physicians and nurse practitioners are responsible for ordering medications for pain, sedation and withdrawal treatment, usually in consultation with pharmacists; nurses are responsible for implementing non-pharmacological treatments, creating and maintaining a calm environment for the patient, for administering medications for pain, sedation and withdrawal treatment, and for monitoring the patient response to treatments."

Dr. Franck concluded, "The most important actions to improve the management of children requiring opioid treatment are: a thorough history and physical to identify or rule out any factors that increase the child's risk for pain, withdrawal or adverse effects to any of the medications; use of age, condition and setting-appropriate validated pain and sedation assessment tools; knowledge of the age- and condition-related pharmacodynamics of the specific drugs to be used; use of evidence-based guidelines for treatments; and a robust quality improvement program to ensure care processes and outcomes are tracked and opportunities for improvement are identified and acted on."

SOURCE: http://bit.ly/Js9Uqh

Pediatrics 2014;133:152-155.

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