Effects of an opioid taper algorithm in hematopoietic progenitor cell transplant recipients

Opioid withdrawal signs and symptoms in children: frequency and determinants

OBJECTIVES

The purpose of this study was to, in a pediatric population, describe the frequency of opioid withdrawal signs and symptoms and to identify factors associated with these opioid withdrawal signs and symptoms.

BACKGROUND

Opioids are used routinely in the pediatric intensive care population for analgesia, sedation, blunting of physiologic responses to stress, and safety. In children, physical dependence may occur in as little as 2-3 days of continuous opioid therapy. Once the child no longer needs the opioid, the medications are reduced over time.

METHODS

A prospective, descriptive study was conducted. The sample of 26 was drawn from all patients, ages 2 weeks to 21 years admitted to the Children's Hospital of Richmond pediatric intensive care unit (PICU) and who have received continuous infusion or scheduled opioids for at least 5 days. Data collected included: opioid withdrawal score (WAT-1), opioid taper rate (total dose of opioid per day in morphine equivalents per kilogram [MEK]), pretaper peak MEK, pretaper cumulative MEK, number of days of opioid exposure prior to taper, and age.

RESULTS

Out of 26 enrolled participants, only 9 (45%) had opioid withdrawal on any given day. In addition, there was limited variability in WAT-1 scores. The most common symptoms notes were diarrhea, vomit, sweat, and fever.

CONCLUSIONS

For optimal opioid withdrawal assessments, clinicians should use a validated instrument such as the WAT-1 to measure for signs and symptoms of opioid withdrawal. Further research is indicated to examine risk factors for opioid withdrawal in children.

Opioid tapering in children: a review of the literature

PURPOSE

To synthesize and critically analyze literature related to pediatric opioid withdrawal.

DESIGN

Critical review of literature related to pediatric opioid tapering and withdrawal.

METHODS

Studies published in peer-reviewed journals were systematically searched using Cochrane, MEDLINE, CINAHL, and PsychINFO. Articles meeting the inclusion criteria were reviewed and analyzed for themes and similarities.

FINDINGS

The majority of published research has focused on the episodic nature of withdrawal symptoms during opioid tapering. Only 1 study produced a valid and reliable pediatric opioid withdrawal symptom assessment-instrument and 1 study produced a valid and reliable pediatric opioid and benzodiazepine symptom assessment instrument. One study conducted in an adult and pediatric population analyzed the effect of the use of an opioid taper algorithm on occurrence and nature of opioid withdrawal symptoms.

CONCLUSIONS

The scope of research on pediatric opioid withdrawal is limited. Studies examining the effect of an opioid taper algorithm on incidence of withdrawal symptoms in children are sorely needed. Further validation of the 2 withdrawal assessment tools for children is warranted.

Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients

The purposes of this prospective repeated measures study were to: (a) describe the occurrence of withdrawal symptoms with the use of a standardised protocol to slowly taper opioids and benzodiazepines; and (b) to test the predictive validity of an opioid and benzodiazepine withdrawal assessment scoring tool in critically ill infants and young children after prolonged opioid and benzodiazepine therapy. Fifteen children (6 weeks-28 months of age) with complex congenital heart disease and/or respiratory failure who received opioids and benzodiazepines for 4 days or greater were evaluated for withdrawal symptoms using a standardized assessment tool. Thirteen children showed moderate to severe withdrawal symptoms a median 3 days after commencement of tapering. Symptom intensity was not related to prior opioid or benzodiazepine exposure, extracorporeal membrane oxygenation (ECMO) therapy or length of tapering. Children who received fentanyl in addition to morphine more often exhibited signs of withdrawal. This study demonstrated that significant withdrawal symptoms occur in critically ill children even with the use of a standardised assessment tool and tapering management protocol. The predictive validity and utility of the Opioid and Benzodiazepine Withdrawal Score (OBWS) was adequate for clinical use, but areas for further improvement of the tool were identified. Problems with the clinical withdrawal prevention and management guidelines were also identified. More research is needed to establish the optimal methods for prevention and management of iatrogenic opioid and benzodiazepine withdrawal in paediatric critical care.