New Guideline on Opioid Withdrawal in Children

Pauline Anderson

January 09, 2014

Children's use of prescription opioids is growing, but until now there has been no guideline on managing withdrawal in this age group. Since abrupt discontinuation of these drugs can lead to discomfort, it's important to follow a set approach to opioid weaning.

That's the conclusion of a new Clinical Report by the American Academy of Pediatrics (AAP) Committee on Drugs and Section on Anesthesiology and Pain Medicine looking at iatrogenically induced opioid dependence and withdrawal in children.

The aim of the new paper, published online December 30 in Pediatrics, is to raise awareness, according to a lead author, Jeffrey Galinkin, MD, professor, anesthesia and pediatrics, University of Colorado Health Science Center, Denver, and director, Scientific and Medical Affairs, CPC Clinical Research, Aurora, Colorado.

"The key reason the AAP was keen to publish this paper and go forward with this guideline is that people are unaware that patients can get drug-specific withdrawal symptoms from opioids as early as 5 days to a week after having been on an opioid chronically."

Prescriptions Doubled

Opioid prescriptions to children have more than doubled in the past decade. In 2009, about 7.2 million outpatient opioid prescriptions were dispensed for youngsters in the United States. Interestingly, the biggest prescribers are dentists, said Dr. Galinkin. Opioids are used primarily short term for pain related to a procedure or an acute injury.

Dr. Jeffrey Galinkin

Withdrawal symptoms can occur when opioid administration is abruptly decreased or discontinued, or when an alteration in gastrointestinal absorption leads to decreased absorption of an oral opioid and a subsequent decrease in opioid blood concentrations. Withdrawal symptoms can also occur when oral dosing results in a significantly lower blood concentration of opioid than a previous intravenous dosing.

Behavioral manifestations of withdrawal include anxiety, agitation, insomnia, and tremors. Physiologic changes linked to withdrawal include increased muscle tone, nausea, vomiting, diarrhea, decreased appetite, tachycardia, fever, sweating, and hypertension.

Opioid withdrawal symptoms can occur in as little as 5 days, although there is considerable patient variability. Most patients who take an opioid for less than a week don't suffer from withdrawal and can have their medication discontinued quickly.

However, a prevention approach is preferred for those exposed for longer than 14 days. These children will usually need to be weaned, by gradually decreasing the opioid dose over time.

Pain Assessment

It's critical, said the authors, to assess a patient's pain status at the time of weaning. The only validated tool to assess withdrawal symptoms in children is the Sophia Observation Withdrawal Symptoms Scale. Clinicians should consistently use and become familiar with this or other scales to detect early signs of withdrawal.

"It doesn't matter which scale you use; it's just that that one happens to be validated in children," said Dr. Galinkin.

The weaning protocol should take into account the length of opioid exposure and total daily opioid dose. There's no clear outcome-based evidence to support an ideal weaning protocol, but it seems logical that individual patient response is more important than following a rigid schedule, said the authors.

The generally accepted approach, however, involves transition to a longer-acting opioid formulation, such as methadone, extended-release morphine, or extended-release oxycodone. Weaning is usually accomplished by steps of a 10% to 20% decrease in the original dose every 24 to 48 hours.

The weaning process may get more difficult as time goes on, added Dr. Galinkin. "Initially, if you're dropping 10% at a time, then you're dropping from 100% to 90%, but when you get to dropping from 20% to 10%, you're halving the dose."

Additional rescue opioid should be considered for severe withdrawal symptoms. A shorter-acting opioid should be on hand for signs of withdrawal or breakthrough pain.

The key is to stay calm when kids who are being weaned off opioids exhibit symptoms. "A lot of people will go right back up to the original dose, so if they're down 40% or 50% on the dose, they will jump back to the original dose; you see this in the hospital setting all the time," said Dr. Galinkin.

"The key is not to panic and to go back, to give a rescue that you have in place, an extra dose of opioid if you need it, go back up to the last level you were at, and then decrease a little bit slower."

If you take the suggested decreasing approach, "you can usually get someone off opioids in a couple of weeks," said Dr. Galinkin.

Behavioral strategies, such as biofeedback, might be a useful part of a weaning program to help with sleep hygiene, anxiety/mood symptoms, and pain-related symptoms, said the authors.

Benzodiazepine Withdrawal

Children who take opioids may also be exposed to benzodiazepines long term. There are also no clear guidelines for concurrent weaning of benzodiazepines and opioids, although it might be "prudent" to wean patients 1 medication at a time, according to the authors.

"I generally wean the opioid first and then the benzodiazepine because benzodiazepines themselves tend to help with opioid withdrawal," said Dr. Galinkin.

As more and more opioids are being prescribed to children, "withdrawal is becoming a bigger and bigger problem," said Dr. Galinkin. He recommends keeping patients on opioids for the shortest possible period of time.

"The problem is that opioids are being used for more and more conditions and I think that the long-term effects of these drugs are unrecognized. Not only are dependence and withdrawal important issues, but we're starting to find out a lot more about the negative effects of opioids."

The current guideline is for children; a separate guideline was developed in 2012 for opioid withdrawal in neonates, also published in Pediatrics.

Pain management expert William M. Hooten, MD, associate professor, anesthesiology, Mayo Clinic, Rochester, Minnesota, called the new AAP guideline for opioid withdrawal in children "interesting and timely."

Dr. Galinkin is on the AAP Committee on Drugs (2012 to 2013).

Pediatrics. 2014;133:152-155. Published online December 30, 2013. Abstract


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