The opioid crisis has greatly affected not only adults but also children as well. As clinicians develop effective approaches to minimize pain and distress in children, the risks and benefits of opioids must be carefully considered. Children of parents with opioid use disorder are also at risk of living in unstable environments, performing poorly academically, engaging in future drug use, and having increased stress, which affects their development before entering adulthood. This statement focuses on the effects of the opioid crisis on children and adolescents and is intended to inform institutional policies, improve education, advocate for evidence-informed guidelines, and improve the care of children affected by the opioid epidemic who are seen in the emergency department.

Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non-pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.

A 3-year-old vaccinated male with no significant past medical history presented to the pediatric emergency department (ED) with a chief complaint of cough. By history, he had a cough and nasal congestion for 1 week and a sore throat for the past 24 hours. There was no history of fever or dyspnea. His history was also negative for trauma or recent travel. He was tolerating solids and liquids well. He was taking a cough suppressant and ibuprofen with some symptomatic relief. In the ED, he was noted to be well appearing, afebrile, and hemodynamically stable, with the following initial vital signs: temperature 36.7°C, pulse 113, respiratory rate 23, pulse oximetry 98% on room air. His physical examination was remarkable for nasal congestion and an erythematous pharynx. He was able to drink fluids and was initially discharged home with a diagnosis of a viral syndrome. Three days later, he presented to another pediatric ED with congestion, sore throat, and now torticollis. He awoke that morning with limited range of motion of his neck and some drooling. He had a tactile fever the day prior which self-resolved. There was no history of vomiting. On this presentation, he had the following vital signs: temperature 37.5°C, pulse 121, blood pressure 102/60, respiratory rate 24, pulse oximetry 100% on room air. His physical examination was remarkable for a well-appearing and well-hydrated child with diffuse neck tenderness without associated lymphadenopathy. In addition, he had left-sided torticollis. There was no significant trismus or evidence of meningismus. Laboratory evaluation was remarkable for an elevated WBC (24.1 K/µL), an elevated CRP (2.07 mg/dL), mild hypoglycemia (65 mg/dL), and slightly low serum bicarbonate level (18 mmol/L). Due to concerns for a possible retropharyngeal abscess, a soft tissue neck plain film was obtained. This revealed a diffuse paravertebral swelling and a 2.2 cm linear radiopaque density (Figure 1). This density was visualized on the lateral view only which was concerning for a possible foreign body. On further questioning with family, the patient’s mother admitted that the patient had been eating fish earlier in the week. He was given a dose of antibiotics and transferred to another pediatric facility for a consultation with a pediatric otolaryngology (ENT) surgeon.

Background: Minority children have been shown to receive fewer opioid analgesics for acute pain. Objective: Assess if both White and non-White physicians prescribe fewer opioids to non-White children presenting to the pediatric emergency department (PED) with upper extremity (UE) fractures. Methods: Patients with acute UE fractures were evaluated. Attending physicians provided their self-identified race and consented to analysis of their opioid prescribing practices. Primary outcome was receipt of an opioid prescription at discharge. Bivariate analyses measured the association between patient race and receipt of an opioid prescription; further analysis evaluated the effect of physician race on prescription practices. Generalized linear models measured these associations while controlling for confounders. Results: Thirty-four percent of eligible patients (2754/8155) were discharged with an opioid prescription. There was no statistically significant difference in odds of being discharged with an opioid prescription for non-Hispanic Black (NHB) compared to non-Hispanic White (NHW) patients. There was no statistically significant difference in odds of prescribing opioids by both White physicians and non-White physicians. In patients with the most severe fractures, requiring sedation for reduction, NHB patients had lower odds of receiving an opioid prescription (OR 0.80; 95% CI: 0.65–0.98). Conclusion: Within our institution, NHB patients received fewer opioid prescriptions at discharge for UE fractures. There is no statistically significant association between NHB race and odds of receiving an opioid prescription. In patients sedated for fracture reductions, NHB patients had lower odds of receiving an opioid prescription and non-White physicians had lower odds of prescribing opioids to NHB patients compared to NHW patients.

Cannabis is the most used recreational drug in the United States, and its use is increasing among children and adolescents.  With the increase in legalized use, there have been increases in intentional and accidental cannabis exposure in the pediatric population. There is also minimized perceived risk.  We review the current use of cannabis and its derivatives, the drug effects and clinical presentation, common misconceptions, pharmacology, and epidemiology. Finally, we review some long-term consequences of cannabis use.