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Evidence Based Strategies: When Is It OK to Prescribe Opioids for Acute Pain? Recommendations Based on the American Academy of Pediatrics Clinical Practice Guideline

After peaking in the early 2010s, opioid prescribing declined due to increased government oversight and guidelines created because of the opioid-related overdose crisis.1 Many clinicians hesitate to prescribe opioid medications because of concerns about adverse effects, tolerance, misuse and the potential for overdose. However, when used appropriately and as part of a multimodal pain regimen, opioids can play an important role in the treatment of acute pain, and in some cases, chronic pain in pediatric patients. Failure to adequately treat pain can have significant short- and long-term consequences. Undertreated pain can contribute to decreased mobility, impaired participation in daily activities, sleep disturbances, emotional distress such as anxiety and depression, and delayed recovery. Persistent, poorly controlled pain may lead to central sensitization, a process in which the changes within the nervous system result in heightened pain perception and increased sensitivity to future pain stimuli. This article aims to summarize the most clinically relevant recommendations from the 2024 American Academy of Pediatrics (AAP) Clinical Practice Guideline (CPG) on opioid prescribing for acute pain in the outpatient setting.

Safe Prescribing

Opioid therapy should be considered for severe acute pain when pain is anticipated to be inadequately controlled with non-pharmacological interventions and non-opioid medications alone, and when the expected benefits of opioid treatment outweigh the risks.1 Opioids should be prescribed as part of a multimodal approach and NOT prescribed as monotherapy. When opioids are prescribed for acute pain, the duration of therapy should be limited to the shortest course necessary, with a supply of five days or fewer unless the pain is secondary to trauma or surgery with an expected duration of pain greater than five days. Immediate-release opioids are preferred over extended-release formulations because they are associated with less risk of overdose and opioid use disorder (OUD).2 Clinicians must exercise caution when prescribing opioids with other central nervous system depressants, particularly benzodiazepines, due to the risk of sedation and respiratory depression. Naloxone should always be prescribed with opioids and is particularly important if a benzodiazepine has been prescribed as well.2,3 Education should be provided on administration of naloxone, and counseling should be provided on safe use, storage and disposal of opioids as well as potential opioid-induced adverse effects including constipation, pruritus, nausea, vomiting, sedation, respiratory sedation and tolerance. The patient’s controlled substance prescription history should be reviewed through the Prescription Drug Monitoring Program (PDMP) prior to prescribing opioids.2

Multimodal Analgesia

Pediatric pain management should emphasize a multimodal approach that incorporates non-pharmacologic interventions and non-opioid medications, as well as opioids when appropriate. Nonpharmacologic strategies may include heat or cold therapy, massage, transcutaneous electrical nerve stimulation (TENS), physical therapy, music therapy, cognitive behavioral therapy, relaxation techniques, guided imagery, acupuncture and aromatherapy. Non-opioid medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered first-line pharmacologic therapy for many acute pain conditions. Additional agents may be considered based on the underlying pain mechanism. Topical therapies, such as lidocaine and capsaicin, may be beneficial for certain localized pain conditions. For neuropathic pain, adjuvant medications including gabapentinoids and certain antidepressants may be appropriate. Muscle relaxants may also be considered when pain is associated with muscle spasm.4 Medication selection should be based on the patient’s age, developmental level, diagnosis and individual preferences.

Tramadol and Codeine Considerations

Codeine and tramadol pose significant safety risks in pediatric patients because their efficacy and toxicity are highly dependent on individual metabolic variability.

Codeine and tramadol are opioid analgesics that function as prodrugs and require hepatic metabolism by the CYP2D6 enzyme to form their active metabolites. Approximately 10% of codeine is converted to morphine, while tramadol is converted to its active metabolite, O-desmethyltramadol. Pediatric patients who are CYP2D6 ultra-rapid metabolizers may produce excessive amounts of these active metabolites, increasing the risk of oversedation, respiratory depression and death. In 2017, the U.S. Food and Drug Administration (FDA) updated its safety warnings and contraindicated the use of codeine and tramadol in children younger than 12 years. The FDA also recommends against their use in adolescents aged 12 to 18 years who have obesity, obstructive sleep apnea or severe pulmonary disease, as these conditions may increase the risk of serious breathing complications.5 Additionally, codeine and tramadol are not recommended during breastfeeding because they can be transferred through breast milk and may expose infants to potentially toxic drug levels.2

At-Risk Populations for Poor Pain Control

It is important to acknowledge that inequities in pain management exist across pediatric populations, with Black and Hispanic patients less likely to receive adequate analgesia. Contributing factors may include implicit bias, systemic inequities, cultural difference in pain expression and reporting, and barriers to health care access.6 Similarly, pediatric patients with physical, developmental or intellectual disabilities may be at risk for undertreated pain, particularly when communication challenges affect their ability to self-report symptoms. Accurate pain assessments are the cornerstone of effective pain management, and clinicians should consider caregiver input. For patients with intellectual or developmental disabilities who may have difficulty communicating pain, validated observational assessment tools can be used to identify and measure pain-related behaviors.7 Awareness of potential disparities and the use of appropriate assessment strategies are essential to ensure that all pediatric patients receive effective pain management.

Final Thoughts

Opioids have been an integral part of pain management for thousands of years and remain part of the modern-day pain medicine armamentarium. By incorporating them as part of a multimodal approach and following proper precautions, patients can significantly benefit without significant risk.

 

 

References:

  1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1
  2. Hadland SE, Agarwal R, Raman SR, et al. Opioid prescribing for acute pain management in children and adolescents in outpatient settings: clinical practice guideline. Pediatrics. 2024;154(5):e202406875. doi:10.1542/peds.2024-068752
  3. U.S. Food and Drug Administration. FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder. July 23, 2023. https://www.fda.gov/drugs/drug-safety-communications/fda-recommends-health-care-professionals-discuss-naloxone-all-patients-when-prescribing-opioid-pain
  4. Carr D. Management of acute pain in the patient chronically using opioids for non-cancer pain. In: Connor RF. UpToDate. UpToDate; 2026. Last updated June 4, 2025. https://www.uptodate.com/contents/management-of-acute-pain-in-the-patient-chronically-using-opioids-for-non-cancer-pain
  5. Fortenberry M, Crowder J, So TY. The use of codeine and tramadol in the pediatric population—what is the verdict now? J Pediatr Health Care. 2019;33(1):124-125. doi:10.1016/j.pedhc.2018.04.017
  6. Hirani S, Benkil B, Odonkor CA, et al. Racial disparities in opioid prescribing in the United States from 2011 to 2021: a systematic review and meta-analysis. J Pain Res. 2024;17:3639-3649. doi:10.2147/JPR.S477128
  7. El-Tallawy SN, Ahmed RS, Nagiub MS. Pain management in the most vulnerable intellectual disability: a review. Pain Ther. 2023;12(4):939-961. doi:10.1007/s40122-023-00526-w
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