Research In Practice Blog
Pain Management for Adolescents
Musculoskeletal injuries, including nonoperative fractures, sprains and strains, are among the leading reasons that children and adolescents visit emergency rooms. While opioids are often used for acute pain management after an injury or surgery, there are increasing concerns around short and long-term risks. Acutely, opioids can cause sedation, nausea/vomiting and respiratory depression. Prescription opioid exposures are also associated with development of an opioid use disorder (OUD), which affects an estimated 1 in 100 adolescents aged 12 to 17. Researchers are actively working to identify safe and effective non-opioid and opioid-sparing pain management options and how to identify patients at elevated risk of opioid misuse and/or OUD development.
“Clinicians have long struggled to find the right balance between providing pain relief and minimizing risk. We aim to ensure that young patients have adequate pain management while also avoiding unnecessary exposure to opioids,” said Tori Sutherland, MD, MPH, an attending anesthesiologist at CHOP and a core faculty member at Clinical Futures, a CHOP Research Institute Center of Emphasis.
Dr. Sutherland and her collaborators co-authored a new study in JACC Journals, and an article published in JAMA Network that focus on understanding and addressing factors associated with development of opioid use disorder and evaluating safe, effective pain management options. Authors focus on providing appropriate pain treatment, identifying at-risk individuals, reducing their exposure to risk factors, and implementing evidence-based interventions to prevent adverse events. In the paragraphs below, we dive into each study.
Prior to the publication of the No OUCH trial in JAMA, there was uncertainty that acute pain related to an injury could be appropriately managed without opioids. Implementing strategies for the safe and effective management of acute pain in pediatric patients can improve treatment outcomes and reduce the risk of substance abuse. The overuse of substances like opioids for pain management is a national issue driven by identifiable risk factors and modifiable behaviors. Identifying broader clinical and policy implications, such as screening, prevention, and treatment strategies can reduce harm.
This analysis of U.S. commercial insurance claims identifies that individuals with congenital heart disease (CHD) have high prevalence of opioid use disorder (OUD) and other substance use disorders (SUDs). CHD is the most common congenital disorder, and advancements in medical care have allowed many people born with CHD to live into adulthood. However, these patients often endure repeated medical encounters, experience chronic pain, and face ongoing health issues, including repeat surgeries with likely opioid exposures that may impact their mental health and increase the risk of non-medical substance use.
Researchers examined a commercial insurance claims database between 2012 and 2022 and identified a total of 73,046 patients with CHD diagnoses, categorized by their physiology and expected procedural needs: simple biventricular, complex biventricular, and single-ventricle physiology. The study focused on identifying the prevalence of OUD, non-opioid SUDs (including alcohol, cannabis, amphetamines, nicotine, etc.), overdose events, and mental health diagnoses.
OUD was most prevalent among patients with simple biventricular physiology (3.6%), followed by those with single-ventricle physiology (3.5%), compared to 1.8% among those with complex biventricular disease. OUD diagnoses were most strongly associated with mental health diagnoses, particularly mood disorders and anxiety diagnoses. Patients with simple biventricular defects and those with single-ventricle physiology had higher prevalence of mood disorders, trauma-related disorders, and sleep disorders—conditions that are known to increase the risk for substance use disorders.
“People born with heart defects exhibit high prevalence of opioid and other substance use disorders. Mental health issues—not just the complexity of the heart defect or the number of surgeries performed—appear to be the strongest predictors of who is likely to develop these conditions. Clinicians should actively screen for mental health conditions and substance use, and ensure that patients are connected to proper care,” said Michael L O'Byrne, MD, MSCE, study co-author, a core faculty member at Clinical Futures, and Director of Clinical Research at CHOP’s Cardiovascular Institute (CVI) and Cardiac Center. “Clinicians should actively screen for mental health conditions and substance use and ensure that patients are connected to proper care.”
Cardiologists, primary care clinicians, and care teams working with individuals who have congenital heart disease (CHD) should be vigilant about the potential for mental health conditions and high-risk substance use, even among patients with decreased disease complexity. Regular screening for mental health disorders and substance use, along with access to evidence-based prevention and treatment, can help prevent the development of opioid use disorder (OUD) and substance use disorder (SUD) in this growing population.
Families of patients should be informed about these risks and provided with appropriate resources, as preventive measures are especially crucial as more children with CHD are surviving into adulthood. By understanding which patient characteristics are associated with increased risk for OUD and SUD development, clinicians can combine general screening with targeted assessment and support.
In an editorial published in JAMA Network, Dr. Tori Sutherland, along with colleagues from Harvard Medical School, discuss the most common pain treatments for pediatric musculoskeletal injuries, which were compared in two landmark clinical trials conducted by Dr. Samina Ali et al. Findings support that opioids are not needed for effective pain relief in most patients who present to the emergency room (ED) with severe pain related to acute nonoperative musculoskeletal injuries. Results offer reassurance to families and clinicians that ibuprofen alone is often effective in managing acute pain.
The No OUCH trial group prospectively randomized children to one of three pain management treatments:
- Ibuprofen alone
- Ibuprofen combined with acetaminophen
- Ibuprofen combined with hydromorphone
Findings demonstrated that two hours after administration, pain scores decreased consistently across all three groups, with no significant differences indicating that one treatment was more effective than the others. Moreover, researchers found that adverse events were over four times more frequent in the group receiving hydromorphone compared to those receiving ibuprofen alone or ibuprofen with acetaminophen.
"For families, these findings provide clarity: their child is unlikely to benefit from a stronger medication than ibuprofen for adequate pain relief. In fact, using an opioid could lead to unnecessary central nervous system or gastrointestinal side effects," said Dr. Sutherland.
Clinical Implications:
The findings from both studies are significant because they underscore the fact that there is considerable uncertainty among the public regarding the safe and effective management of acute pain, as well as preventing adverse outcomes related to opioid use.
It is vital for pediatric clinicians to be aware of the potential dangers of opioid exposures and effective non-opioid and opioid-sparing alternatives. Knowledge gaps addressed by these studies can be applied to develop effective, safe pain management strategies to and avoid unnecessary opioid exposures, thus reducing short and long-term adverse outcomes, including addiction. By prioritizing prevention, we can ensure a healthier future for our youth.
Citations:
Ho, F, Padiyath, A, Nicolson, S. et al. Association Between Congenital Heart Disease Complexity, Mental Health Conditions and Opioid Use Disorder. JACC Adv. 2025 Dec, 4 (12_Part_2).
Calihan JB, Sutherland TN, Hadland SE. Safe and Sufficient—Ibuprofen for Pediatric Musculoskeletal Injuries. JAMA. 2026;335(10):856–858. doi:10.1001/jama.2025.25528