Short-acting versus long-acting opioids for pediatric postoperative pain management

ABSTRACTIntroduction Opioids are potent analgesics commonly used to manage children’s moderate to severe perioperative pain in children. A wide range of short and long-acting opioids are used to treat surgical pain and will be reviewed in this article.Areas covered Both short- and long-acting opioids contain unique therapeutic benefits and adverse effects; however, due to the side effect profile and safety concerns, lack of familiarity, and evidence with long-acting opioids to treat surgical pain, shorter-acting opioids have traditionally been used in children. Almost all opioids work by binding to the mu receptor. Methadone, a long-acting opioid, is an exception because it also has beneficial N-methyl-D-aspartate antagonist properties. Clinically methadone’s properties could translate to improved analgesic outcomes, reduced risk of adverse events, less risk for acute hyperalgesia, tolerance and abuse potential, faster recovery, and reduced risk for chronic persistent surgical pain. This review article summarizes and compares the evidence of commonly used short and long-acting opioids for perioperative pain control in the pediatric population.Expert opinion Individualized methadone therapy using pharmacogenomics has the potential to transform opioid use in pain management by improving patient safety and analgesic outcomes, thereby addressing the gaps in current standardized ERAS protocols.KEYWORDS: Long-acting opioidsmethadoneopioidspainpediatricpostoperative painshort-acting opioids Article highlights Short-acting opioids are fast-acting and have a shorter duration of action, reducing the time of side effects and postoperative analgesia.Methadone is a long acting opioid with additional NMDA antagonistic properties providing extra protection against chronic postsurgical pain, reduced risk of opioid hyperalgesia and tolerance, and minimal abuse potential.Methadone-based multimodal analgesia protocol improved postoperative analgesia, offering opioid-sparing results, reducing opioid-related adverse events and a shorter stay.The metabolism, analgesic response, and side effects of methadone vary significantly due to CYP2B6 polymorphisms, which may explain interindividual differences in analgesic outcomes and PONV.The choice of opioids for perioperative analgesia in children depends on multiple factors, but the type and length of surgery are robust and decisive indicators.Declaration of interestS Sadhasivam has received NIH funding: R01HD089458 (PI: Sadhasivam), R21HD094311 (PI: Sadhasivam), R01HD096800 (PI: Sadhasivam), R44DA055407, R44DA056280, R41DA053877 (MPI: Sadhasivam), R01DA054513 (MPI: Chelly/Sadhasivam) and U01TR003719 (PI: Sadhasivam). S Sadhasivam received pay from UpToDate: Anesthesia for Tonsillectomy and Neuroptics, Inc for studying opioid-induced respiratory depression in pediatric tonsillectomy. S Sadhasivam is one of the inventors in the approved U.S. patents focused on opioid pharmacogenetics: U.S. Patent No. 9944985, 10662476, 16/850537, 16/946401, 16/946399, 10878939. He is the founder and chief medical officer of OpalGenix, Inc. There is no financial conflict with the current article. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.Reviewer disclosuresPeer reviewers on this manuscript have no relevant financial or other relationships to disclose.Additional informationFundingS Sadhasivam has received NIH funding: R01HD089458 (PI: Sadhasivam), R21HD094311(PI: Sadhasivam), R01HD096800 (PI: Sadhasivam), R44DA055407, R44DA056280, R41DA053877 (MPI: Sadhasivam), R01DA054513 (MPI: Chelly/Sadhasivam) and U01TR003719 (PI: Sadhasivam).