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Opioids - Part One

Rita Agarwal MD and Lisa Patel, MD
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Rita and Lisa discuss safe prescribing practices in the age of the opioid epidemic.  Rita outlines when opioids are appropriate for pain management versus when to consider other medications or modalities.  She discusses the PILLS pneumonic to counsel families on storage, safety, and disposal of these medications. And she discusses how to manage patients with difficult to treat pain syndromes.

 
  • Children can be exposed to opioids at any age. 

    •  Neonatal Abstinence Syndrome (NAS) affects newborns, toddlers/children may have accidental exposures, adolescence is a time when may children get exposed to opioids either because of a surgery and/or the availability of medications in the house from another family member.  There is a higher incidence of suicide in children whose parents abuse or misuse opioids.  

  • Prescribing practices for opioids,  in many clinical settings, have historically been commonplace.  Two examples are in dental offices and post-surgical procedures.  

  • Physicians and dentists have become more aware and overall more judicious in prescribing practices.  

    • Surgeons, in particular, are working to define guidelines around different clinical scenarios; for example, if a patient has “X” surgery, he/she will likely need opioids for “Y” amount of days.

    • This is a good rule of thumb for any clinical setting, if opioids are being prescribed, it is better to provide the amount needed and follow up closely to see whether a prescription may need to be extended.

  • There are many state run databases to track opioid prescriptions.   A national database would be helpful.

  • In some scenarios, NSAIDs may be effective for pain control.  Post-wisdom teeth removal, for example, a patient may need an opioid in the first day or two after the surgery but not after that.  A dermoid cyst removal should be able to be done with a good local anesthetic. 

  • Other pediatric pain medications include codeine and tramadol.  Both have to be metabolized to an active drug to have an effect.  That means that an “ultra-rapid” metabolizer may have an unexpectedly strong response to the medication and may have an overdose and therefore, have a black box warning in pediatrics.

  • Long acting oxycontin may be used in patients with longstanding pain; a common scenario may be oncology patients.

  • Methadone has a lower addiction potential, but is hard to medication to titrate as it has a very long half life.

  • Pediatricians should counsel families regarding left-over or easy to access opioid prescriptions in the home.  They should be locked up and only used as prescribed. Here is the AAP poster for medication storage.  

    • Once the opioids are not needed any more, there are resources available for disposal.  They should not be flushed down the toilet as this creates contamination of a water source.  

  • Safe prescribing practices can be summed up as follows:

    • P - prescribe less

    • I -  inform families about the risk of unused opioids in the home

    • L - lock them up

    • L - local resources

    • S - safe disposal

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Hippo Peds RAP - December 2019 Written Summary 244 KB - PDF

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