At the 2025 NAPNAP National Conference on Pediatric Health Care in Chicago, Illinois, Jessica Spruit, DNP, CPNP-AC, FAANP, discussed the American Academy of Pediatrics' (AAP) first clinical practice guideline (CPG) on "Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings." The guideline seeks to balance effective pain management with opioid safety and addresses disparities in pediatric pain treatment.^1,2

“This is actually a brand new guideline. It's the first of its kind. The AAP really took this on with the intention of promoting appropriate prescribing of opioids,” Spruit stated.

“We know that in the setting of an opioid crisis, certainly there's reason for all of us as clinicians to be cautious and thoughtful about the way we utilize and prescribe opioids in our practice," Spruit added. "But what we also worry about is that some pain is inadequately managed as a consequence of regulations and kind of pulling back on the utilization of those medications which do have a long track record of beneficial use. So it’s all about the thoughtful and appropriate prescribing, and this guideline provides some guidance to promote that.”

Key Recommendations for Clinicians

The guideline emphasizes a multimodal approach to pain management, urging clinicians to combine non-opioid medications and non-pharmacologic therapies when treating acute pain. According to the CPG, opioid monotherapy should not be used for children and adolescents. Instead, opioids should only be used in combination with other pain management strategies.²

Spruit highlighted another significant recommendation:

“The other thing that really stood out to me, which had a really high grade in the quality of evidence, was regarding the disposal of opioids following utilization of that prescription. Excess opioids should be disposed of, and if we provide that education with the mode of disposing it, [such as] talking about DEA take back events, using those mail return envelopes, that's all really helpful in promoting adherence to those recommendations for the families we serve.”

Addressing the Risks of Opioid Misuse

A major concern addressed in the guideline is the risk of opioid misuse among adolescents.

“I think recognizing that opioids are in our communities [is important]. We know that when adolescents report that they've misused an opioid or used it in a way that it was not intended, they've often gathered those leftovers from family and friends,” Spruit noted. “I think that even if you're not prescribing it, being aware of the fact that children, adolescents, and families, have access to these medications and that their proper storage, utilization, and disposal is really important.”

The CPG underscores this issue by recommending that PHCPs educate caregivers on directly observed medication administration and safe storage.²

Opioid Use in Pediatric Populations

While the guideline does not ban opioid use outright, it sets clear restrictions on certain medications.

“So within the guideline, there isn't a specific case that says opioids as a class should not be used. It does suggest that it should never be used as a single therapy. So you should never, when trying to manage pain, only prescribe an opioid,” Spruit clarified. “And there is some guidance regarding restrictions related to codeine and Tramadol, which pediatric providers are likely very familiar with but there is nothing within the guideline that states opioids should never be utilized.”

The guideline explicitly advises against prescribing codeine and tramadol for children under 12 years and for adolescents with conditions like obesity, obstructive sleep apnea, or severe lung disease. It also recommends prescribing immediate-release opioid formulations at the lowest effective dose for age and weight, with an initial supply of five days or fewer, "unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days," according to the CPG.²

“I just think that all of us who are committed to relieving pain in children and keeping children and families safe from the risks of opioids can refer to this document as the first of its kind, and keep an eye out," Spruit said. "The AAP provided some guidance regarding additional research that's necessary, gaps in the evidence, and I think we all have an important responsibility in contributing to filling those gaps and enhancing the guidelines in future editions.”

For the full CPG, click here.

References:

1. Van Damme D, Madded M, Spruit J. Pediatric clinical guidelines update. Presented at: NAPNAP. March 10-13, 2025. Chicago, Illinois.

2. Hadland SE, Agarwal R, Raman SR, et al. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics November 2024; 154 (5): e2024068752. 10.1542/peds.2024-068752