This month, the DEA issued new requirements that all prescribers must complete at least 8 hours of training on opiate use before being able to renew a DEA license. Join Sol and Jason Woods as they discuss these new requirements and dive into the indications and use of opiates in kids.
Pearls:
- Opiates in kids are most often used to treat acute pain.
- Chronic pain should be treated with a multidisciplinary approach and should focus on non-opiate pain control when possible
- Doses are based per kilogram and for younger and opiate naive children, doses should be started at the lowest doses possible. Reassessment of pain is crucial as you are titrating up your doses.
- Morphine
- Starting IV dose 0.05-0.1 mg/kg/dose
- for infants < 6 months the starting IV dose is 0.025 mg/kg/dose
- Side effects include vomiting, histamine release (pruritus)
- Fentanyl
- Prior to giving to patients, it may be a good proactive approach to discuss the reasons why you are giving this medication in the face of negative press and adult outcomes; that is, it is when used in the medical setting it is untainted and has very good pain control
- Starting IV dose 0.5 -1 micrograms/kg/dose (maximum of 100 micrograms/dose)
- Starting intranasal dose 1.5-2 micrograms/kg/dose (maximum of 100 micrograms/dose)
- After one starting dose, pain control can generally be effective without respiratory side effects (so, for example, could send to radiology for imaging of a fracture without concern for respiratory depression)
- Hydromorphone
- Many emergency rooms and hospitals that also see adults do not stock anymore given the drug seeking potential
- Can be a very effective medication for acute process such as a perforated appendicitis, difficult trauma or angulated fracture
- Longer pain control than fentanyl
- Starting IV dose 10-15 micrograms/kg/dose given up to every 3 hours
- Does not generally causes vomiting or pruritus
- Codeine
- Should really never be used in children given the variability in enzymatic conversion (some children will convert very quickly and get too much drug causing respiratory depression and others will not and have very ineffective pain control)
- Meperidine
- Should really never be used in children given metabolites can build up leading to neurotoxicity and seizures
- Chronic pain
- Acute on chronic (for example, children with sickle cell disease with acute pain crises)
- Look at/ask what drug and at what dose has worked well in the past
- If this dose is concerning to you, consider starting at a lower dose with rapid assessments and rapid titration
- Consider use other methods of pain control: NSAIDs, acetaminophen, ketamine, local nerve blocks
- Liquid formulations and initial pediatric dosages of select opiates include:
| Oral Opiate Medication |
Initial Dosage |
| Hydromorphone* |
30-80mcg/kg/dose |
| Morphine |
0.08-0.1 mg/kg/dose (<10kg)
0.1-0.3 mg/kg/dose (10-50kg)
10-20mg/dose (>50kg) |
| Oxycodone (Ox) |
0.025-0.05mg/kg/dose (<6 months old)
0.1-0.2 mg/kg/dose (<50kg) |
| Ox/Acet |
0.1-0.2 mg/kg/dose (based on Ox amount) |
| Hydrocodone (HC) |
Unavailable as a stand alone opiate orally |
| HC/Acet |
0.135mg/kg/dose (based on HC amount) |
*Liquid hydromorphone is not FDA approved in pediatrics, so if used, is off label
- To note, it is almost never recommended to give these medications for home and if you do, the number of doses should be very limited (24-48 hours)
- Oxycodone
- This is preferred to combination liquid opiate/acetaminophen medications to avoid unintentional acetaminophen overdosing
- Hydrocodone with acetaminophen
- Initial dosing based on opiate component - 0.135 mg/kg/dose can be given every 4-6 hours; daily dose maximum is based on acetaminophen component
- Oxycodone with acetaminophen
- Oral dosing is always higher than IV dosing because of first pass liver metabolism
- Opiate prescription duration can be a tricky thing to figure out; a great resource is here in terms of how many doses should be prescribed post-operative (PDF here)
- For nearly all procedures, home prescriptions for opiates are almost never recommended
- Opiate Abuse
- Patients at risk for misusing opiates are those who started using them for an appropriate medical reason
- Other risk factors include: younger age of exposure, having insurance (makes access easier), non-hispanic whites, older adolescents, anxiety
- Screening tools include:
- Opiate Misuse Treatment
- Treatment centers are hard to find but patients require long term care
- Pain specialists are often well equipped to handle misuse/addiction
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