The Potential Impact on Children of the CDC Guideline for Prescribing Opioids for Chronic Pain

In an effort to address the epidemic of opioid misuse and related deaths from overdose in the United States, the Centers for Disease Control and Prevention (CDC) produced the 2016 CDC Guideline for Presc r ibing Opioids for Chronic Pain.1 This document is intended to offer “recommendations for prescribing opioids for chronic pain outside of active cancer, palliative, and end-of-life care.”1 The guideline focuses largely on the risks and benefits of opioid treatment and attempts to offer evidence to support their safe, efficacious, and appropriate use. The current concerns about opioids ensure that this document will receive widespread scrutiny and that there will be extensive discussion regarding the 12 recommendations that are made in the guideline.1 It is a certainty that some will argue that the recommendations unnecessarily restrict opioid use and that individuals will suffer unnecessarily as a result; othersmay feel that the recommendations are too lenient regarding opioid indications and will promote further opioid abuseanddependence.Mostwill argue that theevidence supporting the recommendations is inadequate to justify the conclusions that have been reached. Forbetterorworse, in theory,noneof this isgermaneto the pediatric community because the guideline states in its second paragraph that it is intended to apply to patients 18 years of age or olderwith chronic pain. Unfortunately, the exclusion of children fromthenationaldiscussiononpain isnotnew.The Interagency Pain Research Coordinating Committee on the NationalPainStrategy likewisedidnotconsiderchildren intheir publicdraft.2While theremaybesomepotential secondarybenefit to the pediatric population from the guideline if it does, in fact, limit theexcessavailabilityofopioidsand thepotential for inadvertentopioidpoisoning inyoungchildrenandpilferedrecreational use by adolescents, clearly children and adolescents would benefit from guidelines tailored to their needs. We are concerned, however, that because this guideline is written for primary care clinicians, family physicians and pediatricians will assumethat theycanbeextrapolateddownward to thepediatric population for whom it was not intended. There areunderstandable reasonswhychildrenarenot included in these discussions. The methodological and ethical complexities involved in pediatric pain research have dampened the interest of the research community, and the relatively small market for analgesia that children offer has limited the interest of the pharmaceutical industry in supporting this work. As a result, evidence on which to base clinical decisions is even sparser than that for adults. Yet, there are compelling reasons why pediatric pain should be a part of any national consensus. Children younger than 18 years of age represent nearly one-quarter of the US population. Between 1994 and 2007, the rate at which opioids are prescribed to adolescents 15 to 19 years of age has doubled,3 and on the CDC website, it states that nearly 2 million Americans 12 years of age or older either abused or were dependent on opioid painkillers in 2013.4 Further data are cited that indicate that 2.6 of 100000 persons in the United States between the ages of 15 and 24 years died of a prescription opioid overdose.5 In a study of illicit drug use among teens, opioids accounted for 79% of the significant morbidity and 100% of the deaths.6 Certainly, therefore, this is an issue that impacts children. Despite the importance of the issue, however, as mentioned previously, pain research for children has been limited, at least in part, because it is very different than similar research for adults. There are differences in the physiological, assessment, and psychological factors in children compared with adults that demand the use of different methods to measure efficacy. In addition, the experience of pain and some of the diseases responsible for it are different for children. For example, potent opioid analgesia may be indicated for certain chronic pediatric conditions such as osteogenesis imperfecta, epidermolysis bullosa, and neuromuscular diseases. Although not restricted to children, sickle cell vasoocclusive episodes represent a condition forwhichopioidprescribing should be encouraged and for which opioids may be required as long-term treatment. These syndromes all have a clear underlying pathology that includes nociceptive stimulation that may be reduced or eliminated with opioids. This thoughtful perspective on opioid usewas recently reinforced by the leadership at the US Food and Drug Administration.7 Approaches that embrace a balance between the problemswith opioid prescribing and the treatment of pain in the young are encouraged because data clearly show that poorly treated pain in the young has deleterious long-term consequences on the development of pain systems and related responses, as well as psychological well-being.8-10 Furthermore, the long-term impact of pain on adeveloping organism (ie, a child) may be quite different than on an adult and may suggest more aggressive, or at least different, interventions. Related articles at jama.com and jamainternalmedicine.com Opinion