Fear of opioid addiction and misuse has been instilled into the American public – in many cases rightfully so. However, we are concerned that new guidelines for opioid prescribing in children and adolescents after surgery recently published in JAMA Surgery do not adequately address the intricacies of pediatric pain management. Generalization of these recommendations may unnecessarily scare families and mislead physicians as they determine an appropriate pain management plan for children and adolescent patients post-surgery.
While opioid-free recovery is ideal, it is frequently not feasible especially for extremely painful surgeries. For example, as pediatric anesthesiologist and pain management specialists, we may try to incorporate non-opioid recovery techniques for a child or adolescent that had burn debridement surgery to remove unhealthy tissue from a wound. This could include administering over-the-counter medications like acetaminophen or ibuprofen or providing interventional therapies such as nerve blocks that quiet the nerves that are causing discomfort. But it is not realistic – or wise – for that patient to be expected to have an opioid-free recovery. For these and other painful and extensive surgeries, an opioid-free recovery is not supported by clinical evidence and may set unrealistic surgical and recovery expectations for the patient and their family.
Second, inadequate pain management impacts healing and recovery. Research shows that poorly controlled acute postoperative pain is a predisposing factor for chronic post-surgical pain in adults and children. Physicians should not revert back to the era of under-treating acute pain in children – or anyone for that matter – as it can lead to long-lasting problems.
Lastly, while opioid addiction and diversion among adults is well documented and its devastating impacts are far-reaching, research shows that while some adolescents may misuse opioids and other controlled substances they are in the minority. We absolutely have to be concerned about opioid misuse, but most children are not major contributors to our nation’s opioid crisis. We believe opioids should be used sparingly post-operatively, but fear of misuse and addiction should not prevent appropriate pain management when opioid treatment is clinically indicated.
We agree with the sentiments of many physicians quoted in a recent New York Times article including Dr. Elliot Krane, the chief of pediatric pain management at Stanford Children’s Health, who said, “the concern is that the paper is going to discourage the appropriate use of opioids, though I know that wasn’t the intent of the authors. I think the evidence that opioid abuse is increasing in children is very weak; I think the evidence in children that prescription opioids lead to later abuse isn’t there at all.”
We believe optimal postoperative pain management should provide adequate pain relief, minimize adverse effects, and reduce chances of drug misuse. While we cannot undertreat pain, we also cannot go back to the practice of over-prescribing or unnecessarily prescribing opioids for minor operations. There needs to be a carefully nuanced balance in treating pain, especially for pediatric and adolescent patients.
Going forward there needs to be continued parent and patient education about expectations for recovery post-surgery and proper pain management. This needs to include consistent messaging to families regarding safe use, storage, and disposal of opioids as well as the risks for non-medical use and substance use disorder.
This critically important topic deserves more research and clarification so that the medical community can properly treat pediatric and adolescent pain. Stigmatizing the select use of opioids for children and adolescents after surgery is counterproductive and additional guidance should not emphasize the fear of opioid diversion or misuse over appropriate pain management.
Rita Agarwal is a double board-certified pediatric anesthesiologist at Stanford University and Lucile Packard Children’s Hospital. Her work focuses on pediatric pain management, neuroanesthesia, medical education, advocacy, mentorship, and sponsorship. She serves as chair of the California Society of Anesthesiologists’ Women in Anesthesiology Committee, is active with the ASA and CSA communications committees, and is one of two hosts of the CSA podcast Vital Times.
Dr. Agarwal is an active member of the Society for Pediatric Anesthesia and the Society for Pediatric Pain Medicine, where she contributes to educational and editorial initiatives. A representative sample of her publications includes work on pediatric sedation safety in Pediatrics, anesthesia for pediatric chest trauma in Seminars in Cardiothoracic and Vascular Anesthesia, airway management in laryngotracheal injuries in children in Paediatric Anaesthesia, opioid use in children during the perioperative period, perioperative management of pediatric patients using medicinal marijuana, dental anesthesia safety, outpatient opioid prescribing guidelines for children and adolescents, and safe and effective pain management in children in American Family Physician. She has also written on workforce trends in pediatric anesthesiology, adverse event disclosure, and perioperative considerations for adolescents and young adults with substance use disorders.
She has completed training in evidence-based coaching and is passionate about advocacy for safer care for children undergoing dental anesthesia and appropriate pain management for pediatric patients, while also supporting physicians through mentorship and coaching. She shares updates through her Stanford profile, on X as @ritaagarwal6, on Instagram as @ragarwal62, and on Bluesky as @momdoc3.bsky.social.
Stephen Hays and Vidya Chidambaran are anesthesiologists.
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