Pain is one of the most common reasons children and adolescents seek medical care.¹ Each year, as many as 1 in 30 young people receive an opioid prescription, most commonly for surgical or dental pain.^2,3 Although opioids have long been central to the management of severe pain, many clinicians have been prescribing fewer opioids to children since the early 2010s, likely due to rising rates of opioid use disorder, poisoning, and overdose.^3,4

Although it is critical to reduce inappropriate opioid prescribing, this may also result in the undertreatment of pain, which impacts young people’s physical and psychosocial well-being.⁵ Finding the correct balance in safe and effective opioid prescription is essential. To help guide clinicians, we led the development of the first American Academy of Pediatrics (AAP) clinical practice guideline on the topic, Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings.⁶

The guideline is intended for clinicians caring for patients younger than 21 years in outpatient settings and focuses on acute pain management (ie, less than 1 month). We convened an expert panel to review the evidence on best practices for pain treatment, with representation from families impacted by undertreated pain, general pediatrics, surgery, pain medicine, anesthesia, addiction medicine, emergency medicine, adolescent medicine, and quality improvement. We finalized a set of key action statements arising from the evidence and published an accompanying technical report.⁷

Key action statements focus on optimizing nonpharmacologic approaches and nonopioid medications, prescribing opioids safely and appropriately, minimizing risk for poisoning and overdose, and managing acute pain in young people with preexisting chronic pain or using long-term opioid therapy. Throughout, the guideline aims to ensure equitable treatment of pain in young people, addressing disparities whereby Black, Hispanic, and Indigenous people, as well as individuals with disabilities, have historically received less adequate and timely pain management than others.^8,9

The key action statements align with recommendations from the US Centers for Disease Control and Prevention and the US Food and Drug Administration (FDA).^10,11 However, three of the recommendations deserve special note.

First, we recommend clinicians reduce or eliminate most codeine and tramadol prescribing. Codeine is a low-potency opioid, and tramadol is a partial opioid agonist. Both have been used for decades in acute pain management, but the FDA issued a contraindication (its strongest warning) against their use in children younger than 12 years and for postoperative pain related to tonsillectomy or adenoidectomy in those younger than 18 years.¹⁰ Based on safety reporting, both medications have been linked to increased risk for respiratory depression and death. The FDA also issued a warning against codeine and tramadol use in adolescents ages 12 to 18 years who have obesity, obstructive sleep apnea, or severe lung disease. Because these medications and their metabolites can be found in breastmilk, the FDA has additionally warned against their use in people who are breastfeeding. Given these recommendations, clinicians can consider avoiding codeine and tramadol altogether in individuals younger than 18 years.

Second, when prescribing opioids, we recommend that clinicians take steps to prevent poisoning and overdose—most notably, coprescribing naloxone. We acknowledge that illicitly manufactured fentanyl (rather than prescribed opioids) is the current leading cause of overdose in young people, and that most young people (94%–99% across studies) will not develop an opioid use disorder after taking an opioid.^6,12 Nonetheless, adolescent overdose deaths recently reached an all-time high.¹² This trend, combined with strong evidence that naloxone prevents overdose deaths in adults and the ease of coprescribing, led our expert panel to recommend universally prescribing naloxone alongside opioids.

Third, for young people with preexisting chronic pain who experience an acute pain episode, clinicians should prescribe opioids when appropriate and continue preexisting long-term opiod therapy without tapering. Many chronic painful conditions such as headaches and musculoskeletal pain should be managed without opioids. However, some young people with conditions such as sickle cell disease, epidermolysis bullosa, and Ehlers-Danlos syndrome may already be on long-term opioid therapy when a clinician first encounters them for the treatment of acute pain. Such individuals often have increased pain sensitivity and may require additional support if they undergo surgery, experience trauma, or have worsened acute pain. They often need higher opioid doses.

Unfortunately, many individuals may be asked to suddenly taper or stop their opioids, particularly when interacting with a new clinician unfamiliar with their long-term pain management. For individuals on long-term opioid therapy, it is crucial to maintain the baseline opioid dosing and appropriately add analgesia without discontinuing or rapidly tapering preexisting opioids; without these measures, untreated pain, worsened mental health, and illicit opioid use may occur.¹³ Effective pain management often requires coordination with caregivers and other clinicians knowledgeable of the patient’s care. Clinicians can differentiate between stable opioid use for chronic pain (in which a young person’s functionality often improves with receipt of their opioid) and an opioid use disorder (in which functionality typically worsens, with loss of control of opioid use and negative life consequences).⁶

Approaches to pain management have changed dramatically in the past 15 years. Trends show that clinicians are prescribing fewer opioids to young people, which is likely appropriate in the context of earlier overprescribing. However, undertreatment of pain leads to distress, worsened health outcomes, and higher care costs. We hope this guideline supports clinicians in rational and equitable opioid prescribing for acute pain and, ultimately, optimal pain management for young people.