Responsible and Safe Use of Opioids in Children and Adolescents in the ED

Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency Department (Pain Management CME, Controlled Substances CME, Pharmacology CME, and Addiction Disorders CME)

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Table of Contents

About This Issue

Opioid medications have an important role in the treatment of moderate to severe pain that cannot be relieved by first-line interventions. Reducing and preventing opioid-related harms, while safely providing care, should be a priority. This issue reviews evidence-based approaches to assessment and management of pain in pediatric patients, with a focus on optimizing nonopioid pain management as a first approach and using opioid medications safely, when appropriate. In this issue, you will learn:

Which pain scales are recommended for children of different ages

Considerations for pain assessment in neonates, infants, nonverbal children, and children with developmental delays

Recommendations for physical, psychological, and pharmacological pain management

Indications for opioids for children

Which opioids should be avoided in children

Recommendations for opioids to consider, based on route of administration

Considerations for using intravenous opioids before sedation

Common adverse events associated with opioids

Risk factors for future opioid-related harms

Tools for opioids risk assessment

Recommendations for safer opioid prescribing

Recommendations for naloxone use in the emergency department and as take-home kits

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Prehospital Care Considerations
  7. Emergency Department Evaluation
    1. Developmental Considerations When Evaluating Pain
    2. Pain Measurement Tools
    3. Pain Assessment in Special Populations
      1. Infants and Neonates
      2. Nonverbal Children
      3. Children With Cognitive Delays
    4. Vital Signs and Pain
  8. Treatment of Pain
    1. Physical and Psychological Management of Pain
    2. Pharmacologic Management of Mild to Moderate Pain
    3. Pharmacologic Management of Severe Pain
    4. Opioids for Pain Management
      1. Opioids That Should Be Avoided in Children
      2. Indications for Opioids for Children
        • Oral Opioids
        • Intranasal Fentanyl
        • Intravenous Opioids 
          • Considerations for Using Intravenous Opioids Before Sedation
      3. Monitoring and Re-evaluation After Opioid Administration
      4. Adverse Events Associated With Opioids
      5. Treatment of Chronic Pain With Opioids
  9. Risk for Future Opioid-Related Harms
    1. Risk Factors for Opioid Misuse
    2. Opioid Risk Assessment
      1. Validated Tools to Screen for Substance Use in Adolescents
  10. Safe Opioid Prescribing
    1. Prescription Drug Monitoring Programs
    2. Measures to Support Safer Opioid Prescribing
      1. Prescribing Limits
  11. Naloxone
    1. Naloxone Use in the Emergency Department
    2. Take-Home Naloxone Kits/Prescription of Naloxone Upon Discharge
  12. Nonopioid Pharmacologic Alternatives: Emerging Treatments
    1. Methoxyflurane
    2. Subdissociative Ketamine
    3. Intravenous Acetaminophen
  13. 5 Things That Will Change Your Practice
  14. Risk Management Pitfalls to Avoid in Administering Opioids to Pediatric Patients
  15. Summary
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. The Continuum of Pediatric Pain Assessment and Treatment in the Emergency Department
  19. Tables
  20. References


Untreated pain in childhood may have ramifications well into adulthood. Opioid medications have an important role in care for moderate to severe pain that cannot be relieved by first-line interventions, but clinicians must approach opioid use in the emergency department in an evidence-based, socially responsible manner. This issue reviews evidence-based approaches to assessment and management of pain in children and adolescents, with a focus on optimizing nonopioid pain management as a first approach and using opioid medications safely, when appropriate. Recommendations are provided for safer opioid prescribing, including assessment of risk factors for opioid misuse, careful family counseling and education, and suggested prescribing limits. Prescription and use of naloxone in the emergency department and as take-home kits are also discussed.

Case Presentations

A 10-year-old girl is brought in via wheelchair by her mother…
  • The girl is developmentally delayed, nonverbal, writhing and moaning, and keeps batting your hands away when you try to examine her. Her temperature is 39.2°C, and her heart rate 150 beats/min. Her mother is tearful, saying that she has never seen her daughter in so much pain.
  • You wonder how you can quickly ease the child's pain so you can figure out what is going on…
A 2-year-old boy with known sickle cell disease is carried into the emergency department triage area by his father…
  • The boy is curled up, still, and tearful. He is afebrile, has a heart rate of 160 beats/min, and has pain with movement of his right upper extremity—the site of his typical vaso-occlusive pain crises. His parents have been treating him at home for the last 24 hours. They have been giving him ibuprofen and the oral opioid medication his hematologist has prescribed. They say they think the home treatment is not working.
  • You begin to think how you will treat this child’s pain quickly and effectively...
A 15-year-old girl fell while skateboarding and sustained a both-bone forearm fracture…
  • You successfully reduced her fracture in the ED and have arranged follow-up with orthopedics in 7 to 10 days. The girl is now ready to go home.
  • The family is asking what to do for pain, now and at home, since the sedation has worn off and her wrist is beginning to throb.
  • What medications should you recommend for at-home use, and how should you advise the family to use them?

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The Continuum of Pediatric Pain Assessment and Treatment in the Emergency Department

The Continuum of Pediatric Pain Assessment and Treatment in the Emergency Department

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Table 3. Screening Tools for Substance Use in Adolescents

Screening Tool Comments
Screening to Brief Intervention* (S2BI)
  • For adolescents aged 12-17 years
  • 7 brief questions
  • Can be self-administered by a patient or administered by a clinician, but the clinician must interpret the score and provide clinical guidance
Brief Screener for Tobacco, Alcohol, and other Drugs* (BSTAD)
  • For adolescents aged 12-17 years
  • Focused on specific substances used in the past year to assess risk for substance use disorder
  • First screens for tobacco, alcohol, and marijuana use; if using any of these, further questions are then added
  • For adolescents aged 12-21 years
  • 6 yes/no questions
  • 1 “yes” response in the emergency department suggests current problematic substance use or risk of substance use disorder
  • 2 “yes” responses suggests a serious problem and need for more urgent further assessment
*These screening tools are validated for use in universal screening in pediatric primary care but have not been tested in the emergency department setting.

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

8. * Hartling L, Ali S, Dryden DM, et al. How safe are common analgesics for the treatment of acute pain for children? A systematic review. Pain Res Manag. 2016;2016:5346819. (Systematic review; 44 studies) DOI: 10.1155/2016/5346819

14. * Goyal MK, Johnson TJ, Chamberlain JM, et al. Racial and ethnic differences in emergency department pain management of children with fractures. Pediatrics. 2020;145(5):e20193370. (Cross-sectional database study; 21,069 visits) DOI: 10.1542/peds.2019-3370

17. World Health Organization. WHO issues new guidelines on the management of chronic pain in children. 2021. Accessed December 1, 2022. (International consensus guidelines)

28. United States Centers for Disease Control and Prevention. Opioid data analysis and resources. Accessed December 1, 2022. (National database)

29. United States Centers for Disease Control and Prevention. Wide-ranging online data for epidemiologic research (WONDER). Accessed December 1, 2022. (National database)

41. * Birnie KA, Hundert AS, Lalloo C, et al. Recommendations for selection of self-report pain intensity measures in children and adolescents: a systematic review and quality assessment of measurement properties. Pain. 2019;160(1):5-18. (Systematic review; 80 articles) DOI: 10.1097/j.pain.0000000000001377

47. * Olsson E, Ahl H, Bengtsson K, et al. The use and reporting of neonatal pain scales: a systematic review of randomized trials. Pain. 2021;162(2):353-360. (Systematic review; 352 studies) DOI: 10.1097/j.pain.0000000000002046

48. * Bailey B, Trottier ED. Managing pediatric pain in the emergency department. Paediatr Drugs. 2016;18(4):287-301. (Review) DOI: 10.1007/s40272-016-0181-5

52. * Krauss BS, Calligaris L, Green SM, et al. Current concepts in management of pain in children in the emergency department. Lancet. 2016;387(10013):83-92. (Review) DOI: 10.1016/s0140-6736(14)61686-x

56. * Ahrari M, Ali S, Hartling L, et al. Nonmedical opioid use after short-term therapeutic exposure in children: a systematic review. Pediatrics. 2021;148(6):e2021051927. (Systematic review; 21 studies, 49,944,602 patients) DOI: 10.1542/peds.2021-051927

66. * Translating Emergency Knowledge for Kids. Bottom line recommendations: pain treatment. 2021. Accessed December 1, 2022. (Consensus summary)

69. * Poonai N, Zhu R. Analgesia for children in acute pain in the post-codeine era. Curr Pediatr Rev. 2018;14(1):34-40. (Review) DOI: 10.2174/1573396313666170829115631

72. EMSC Innovation and Improvement Center, Translating Emergency Knowledge for Kids. Bottom line recommendations: pain treatment. 2022. Accessed December 1, 2022. (National guideline)

75. United States Food & Drug Administration. FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. 2018. Accessed December 1, 2022. (National statement)

76. Heatlh Canada. Non-prescription pain relief products containing codeine are not recommended for use in people under 18 years of age. 2020. Accessed December 1, 2022. (National statement)

80. Health Canada. New safety measures for prescription codeine and hydrocodone to further restrict use in children and adolescents. 2016. Accessed December 1, 2022. (National statement)

99. United States Centers for Disease Control and Prevention. CDC clinical practice guideline for prescribing opioids for Pain. 2022. Accessed December 1, 2022. (Practice guideline)

107. *Cragg A, Hau JP, Woo SA, et al. Risk factors for misuse of prescribed opioids: a systematic review and meta-analysis. Ann Emerg Med. 2019;74(5):634-646. (Meta-analysis; 65 studies) DOI: 10.1016/j.annemergmed.2019.04.019

109. National Institute on Drug Abuse. Screening and assessment tools chart. 2022. Accessed December 1, 2022. (Federal website)

114. Prescription Drug Abuse Policy System. PDMP access and registration. 2016. Accessed December 1, 2022. (Federal website)

120. United States Food and Drug Administration. Where and how to dispose of unused medicines. 2021. Accessed December 1, 2022. (Federal website)

124. *Dyson MP, Dong K, Sevcik W, et al. Quantifying unused opioids following emergency and ambulatory care: a systematic review and meta-analysis. J Am Coll Emerg Physicians Open. 2022;3(5):e12822. (Systematic review; 9 studies) DOI: 10.1002/emp2.12822

126. Naloxone dosage. 2021. Accessed December 1, 2022. (Drug dosing website)

133. World Health Organization. Community management of opioid overdose. 2014. Accessed December 1, 2022. (International statement)

Subscribe to get the full list of 143 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: opioids, opioid medications, pain management, nonopioid pain management, opioid misuse, opioid use disorder, ibuprofen, naloxone, analgesia, pain measurement tools, pain scale, pain assessment, physical pain management, psychological pain management, pharmacologic pain management, nonsteroidal anti-inflammatory drugs, NSAID, oral opioids, intranasal opioids, intravenous opioids, opioid dosing, opioid dosage, adverse events, risk factors, risk assessment, safer opioid prescribing, prescription drug monitoring programs, screening tools for substance use, opioid prescribing limits

Publication Information

Samina Ali, MD, FRCPC; Amy L. Drendel, DO, MS

Peer Reviewed By

Deepa R. Camenga, MD, MHS, FAAP; Reuben J. Strayer, MD

Publication Date

January 1, 2023

CME Expiration Date

January 1, 2026    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Included as part of the 4 credits, this CME activity is eligible for 4 Pain Management credits, 4 Controlled Substances credits, 4 Pharmacology credits, and 1 Addiction Disorders credit, subject to your state and institutional approval.

Pub Med ID: 36592388

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