Opioid Use in Children

While children don’t experience episodes of pain at rates equal to that of adults, 10% of children 5-15 years old and up to 28% of adolescents ages 15-19 years old experience migraines. Tonsillectomies, wisdom teeth extractions and sports-related injuries are other common causes of childhood pain. However, research focused on the epidemiology, etiology, and treatment of childhood pain is lacking, so pediatric patients may receive pain medication regimens that treat them as ‘mini adults’ instead of administering an entirely different treatment course. In a 2012 evaluation of adverse drug reactions in children, 20% of all adverse drug reactions resulted from medications containing analgesics or opioids.

Opioid use in children comes with similar risks as usage in adults, such as tolerance or dependence. For example, 35% to 57% of PICU patients develop opioid tolerance, which often leads to longer hospital stays.  A unique risk to pediatric patients is the potential for long-term opioid tolerance when exposed to opioid therapy during brain development. Severe risks of opioid use in children include respiratory depression or death. These risks have resulted in a change in prescribing recommendations for opioids previously considered safe for pediatric use.  

A study out in this month’s issue of Pediatrics specifically examines the use of codeine, commonly believed to be a safer opioid option with limited risk for children in pain.4 Codeine is widely used as both a cough suppressant and pain medication. A 2011 study on opioid use in pediatrics found that codeine was prescribed to 800,000 patients under the age of 11, making it the most frequently prescribed opioid for children. However, patient response to codeine varies greatly due to the way the drug is metabolized. Some patients exhibit no effect while others demonstrate high sensitivity even at normal therapeutic doses. There is currently no cost-effective and quick way to predetermine an individual’s sensitivity to codeine. Children with high sensitivity are at an increased risk of slowed or difficult breathing.

The FDA reviewed cases of children who were administered codeine from 1965 to 2015 and found 64 cases of severe respiratory depression and 24 deaths. 21 of those deaths occurred in children under the age of 12. This review prompted an FDA advisory panel to vote to discourage the use of codeine as a cough suppressant in children in December 2015. Several other regulatory agencies have followed suit, issuing warnings about the use of codeine for any purpose in children, especially in those under the age of 12.

The growing concern around the safety of codeine and other opioid pain medication use in children has led to a reevaluation of analgesic alternatives like acetaminophen and ibuprofen. More research is needed into the proper use of nonopioid pain medications to lessen the need for opioid use and decrease risk in the pediatric population.

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