Pain Management in Children and Adolescents in Outpatient Settings
The general principles of pain management are similar across the life span. For children and adolescents, like for adults and older adults, clinicians should treat acute pain using a multimodal approach. This can include the appropriate use of nonpharmacologic therapies, nonopioid medications, and, when needed, opioid medications.
Clinicians should avoid inappropriate opioid prescribing but guard against under-treating pediatric pain
Acetaminophen and NSAIDs should be the initial / primary pharmacologic strategy; topical agents (eg, lidocaine, capsaicin, acetaminophen) can also be helpful.
Nonpharmacologic analgesic strategies include:
- Ice or heat
- Massage
- Keeping the injured area elevated to minimize swelling
- Music therapy / age-appropriate relaxation or distraction strategies
- Breathing exercises
If opioids are prescribed:
- They should be used in combination with non-opioid analgesics and non-pharmacologic treatments
- Educate patients and their families on risks / alternatives
- Prescribe immediate-release opioid formulations
- Start with the lowest age- and weight-appropriate doses
- Provide an initial supply of 5 or fewer days, unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days
- Do not prescribe codeine or tramadol due to risk of dangerous oversedation or ineffectiveness due to pharmacogenetic variability
Less than 5% of pediatric patients are prescribed opioids. This is primarily for acute injuries, dental procedure, or surgical procedure. Risk factors for developing opioid use disorder (OUD) include underlying mood/anxiety disorders, comorbid substance use, prescriptions for long-acting opioids, high daily doses, and prescriptions with a duration of 1 week or longer. A family history of substance use disorders can also be a factor.
Assess for Risk of developing OUD
For older children and adolescents, clinicians should conduct a risk assessment that includes screening for mood disorders (depression and anxiety) as well as screening for substance use disorders / substance misuse including alcohol, cannabis, nicotine, and other substances.
It is important to proactively identify at-risk youth to reduce the possibility of developing opioid use disorder (OUD) in the future.
Screening to Brief Intervention (S2BI)
This screening tool consists of frequency of use questions to categorize substance use by adolescent patients into different risk categories. The accompanying resources assist clinicians in providing patient feedback and resources for follow-up.
Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)
This tool consists of frequency of use questions to identify risky substance use by adolescent patients. The accompanying resources assist clinicians in providing patient feedback and resources for follow-up.
CRAFFT
This tool from the Center for Adolescent Behavioral Health Research (CABHRe) is designed to identify substance use, substance-related riding/driving risk, and substance use disorder among youth ages 12-21. These questions can help separate those who are experimenting from those who may be headed for serious trouble and need more in-depth help.
Patient Health Questionnaire for Adolescents (PHQ-9A)
A nine-question depression screening tool that has been modified for adolescents. It asks the teen about lack of pleasure, feelings of hopelessness, sleep problems, lack of energy, problems with eating, feelings of guilt, lack of concentration, movement or speech problems, and suicidal thoughts.
Beck Depression Inventory (BDI)
A 21-questionnaire self-report tool that can be used for the diagnosis of depression.
Generalized Anxiety Disorder 7-item scale (GAD-7)
A quick self-report for teens (ages 13-17) focusing on feeling nervous, unable to stop worrying, and irritability.
Screen for Child Anxiety Related Disorders (SCARED)
More comprehensive, assessing for generalized, separation, social, and school anxiety in youth aged 8-18, with parent and child versions available.
Ask Suicide-Screening Questions (ASQ) toolkit
This toolkit is designed to screen patients ages 8 years and above for risk of suicide.
Pediatric ACEs and Related Life-events Screener (PEARLS)
Screening for ACEs is helpful as it is associated with a dose-response increase in risk for mental health disorders, physical health problems, substance use, and poorer educational outcomes. This resource includes screeners in both English and Spanish.
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SAMHSA National Helpline
A free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders. Number to dial: 1-800-662-HELP (4357)
Adolescents
SMHO-CAMH: Opioids – What You and Your Friends Need to Know
A free brochure for teens sharing information on opioids.
Adolescents
Pain Assessment and Management Initiative (PAMI)
PAMI’s mission is to advance innovation and safety in pain education, patient care, and research. They focus on incorporating nonpharmacologic and nonopioid modalities to improve pain outcomes and reduce opioid risk in patients and special populations, such as older adults, patients with health disparities or at risk for substance abuse, trauma, and postoperative patients. PAMI …
Adolescents
AboutKidsHealth
A health education website for children, youth and their caregivers with several articles about pain management.
Adolescents
LearnAboutTreatment.org: Teen & Young Adult Opioid Use
This resource covers teen & young adult opioid use disorder treatment with fact sheets, videos, and resources including screening tools, clinical guidelines, harm reduction and safety planning, and minor’s health rights.
Adolescents
AAP: Substance Use Treatment – ECHO
This ECHO aims to equip pediatricians and other healthcare professionals with knowledge and skills around screening, referral pathways, and treatment options to address substance use concerns in adolescents.
Adolescents
AAP: Resources to Address the Opioid Epidemic
A web page with general information and links to resources to address the opioid epidemic for pediatric providers, patients, and families.
Adolescents
Partnership to End Addiction: Prevention Tips for Every Age
This resource provides practical, science-based information to help parents protect and support their children. It shares general information for parents on how to talk about substance use and how to prevent substance use.
Adolescents
Government of Canada: Talking with teenagers about drugs and alcohol
A comprehensive webpage with information and tips for parents; includes detailed information about illicit drugs and prevention.
Adolescents
NIH: 8 Tips for Talking (and listening) to your Teens about Drugs and Alcohol
An article guiding caregivers on how to discuss drugs and alcohol with their kids.
Adolescents
NIDA: Drugged Driving Drug Facts
An article with facts on drugged driving. Drugged driving is driving a vehicle while impaired due to the intoxicating effects of recent drug use, putting the driver, passengers, and others who share the road at serious risk.
Adolescents
NIDA: Teachers – Classroom Resources on Drug Effects
Lessons, activities, and drug facts to educate teens about the effects and consequences of drug use.
Adolescents
Operation Prevention
The DEA has joined forces with Discovery Education to provide no-cost online tools that support every member of the community with the power of prevention. Help kickstart life-saving conversations today with standards-aligned English & Spanish-language resources for students in grades 3-12, plus additional resources designed for educators, families, and professionals.
Adolescents
Children’s Healthcare Canada: Pediatric Pain Network Opioid Toolkit
Co-created with Solution for Kids in Pain (SKIP) and its partners, this toolkit summarizes current evidence and resources for safe, effective, and equitable opioid use in managing moderate to severe acute and chronic pain in youth. The information and resources in this toolkit can be integrated into clinical practice, support clinical education, and be used …
Adolescents
HealthyChildren.org: Substance Use
Links to 28 articles covering every aspect of prevention, treatment, and the substances that teens may be exposed to / experiment with.
Adolescents
OPEN: Pediatrics Pain Management
A resource with information for caregivers and providers on pediatric pain management post-surgery.
Adolescents
HealthyChildren.org: How to Talk With Your Teen About Drugs and Alcohol
An article providing advice for parents on discussions about drugs and alcohol.
Adolescents
IASP: Pain in Children – Management
Information for pain management among children and adolescents. Available in multiple languages.
Adolescents
Talking to Teens About Drugs: Real-World Tools for Tough Conversations
A free online course helps school staff use proven techniques to connect with youth about substance use.
Adolescents