Summer 2024

Growing Pains: Key Pharmacy Considerations for Pain Management in Young Workers

Recently enacted and proposed changes to child labor laws in several states have the potential to increase the number of minors in the workforce, but the impact to the workforce remains to be seen (see Child Labor Laws Are Changing: How Could This Impact Workers’ Comp?).

Regardless, it is not uncommon to see a significant population of minors in certain occupations, be it food service, retail, recreational facilities, or other miscellaneous positions.

Recent Trends in Child Labor

 6 million

U.S. teens had a summer job in 20211

1.4 million

teens worked retail jobs in the summer of 20211

Teens make up 24% of the limited-service restaurant workforce2

From a workers’ compensation medical management standpoint, this population is unique for a number of reasons. Specifically, in the event a minor sustains a work-related injury requiring pain management, it is important to understand special pharmacy considerations within this employee population.

Understanding Why Young Workers Require Different Pain Treatment

When it comes to pharmacy management, medications that are commonly prescribed in workers’ comp to adult patients may not be clinically appropriate for younger individuals, as those drugs may not be adequately studied in pediatric populations.3 Additionally, measuring outcomes among minors may be difficult.3

Furthermore, individuals can progress through adolescence at different rates, meaning two young people of the same age could be at vastly different stages of development, and pharmacotherapy may be even more nuanced when compared to adults.

Therefore, it is worth examining some of the most common drug classes in workers’ comp through the lens of treating pain in younger individuals.


Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to treat a variety of different pains and aches for many short and long-term conditions. Commonly used NSAIDs include:


Ibuprofen (Motrin®, Advil®)

Naproxen (Aleve ®)

Celecoxib (Celebrex®)

NSAID Concerns

Prescription strength nonsteroidal anti-inflammatory drugs (NSAIDs) are considered safe and effective for the treatment of pain amongst adolescents,4 with the exception of aspirin.

Different medical organizations vary on their opinions, but many would agree that children under the ages of 16-19 should not use aspirin unless instructed by a doctor due to the risk of Reye’s syndrome, a rare but serious condition that is typically preceded by a viral infection like flu or chickenpox, which causes confusion, swelling in the brain, and liver damage.5-6

While generally considered safe, NSAIDs present potential risks that include:

Cardiovascular concerns, such as high blood pressure which can affect other medical conditions
Gastrointestinal concerns, such as irritation of the stomach and intestinal lining, stomach ulcers, gastric bleeding, and more
Drug-drug interactions
The risk of Reye’s syndrome in children and adolescents with aspirin use


For NSAIDs In Children / Adolescents

Most NSAIDS are generally safe for adolescent use, with similar risks compared with adult use

DO NOT use aspirin in children/adolescents due to risk for serious or even fatal Reye’s syndrome


Acetaminophen – also known as the brand drug Tylenol® – is used to treat minor aches and pains in addition to fever.

Acetaminophen Concerns

Acetaminophen is generally considered safe and effective for the treatment of pain in adolescents. However, acetaminophen comes with the same risks and precautions present in adult use.

Potential risks with acetaminophen include:

Liver damage and liver toxicity
Therapeutic duplication across multiple products

While acetaminophen can be prescribed by a doctor, OTC availability creates the risk of therapeutic duplication, which creates an even greater risk for adolescents, especially as acetaminophen can be found in other prescription and OTC medications, such as cold medicines.

Research indicates that individuals aged 16-23 have limited and unsafe understandings of acetaminophen use, even when consulting the drug label.7

Acetaminophen’s presence as a well-known drug may create the impression that the drug is harmless, which could lead to misuse and overdose. Therefore, it is important to communicate the potential risks of misuse with adolescents.


For Acetaminophen In Children / Adolescents

Acetaminophen is generally considered safe for use in adolescent populations

The risk of therapeutic duplication exists across multiple prescription and OTC medications

Adolescents may have an unsafe understanding of acetaminophen use, which could lead to misuse or overdose


Gabapentinoids are anticonvulsant (anti-seizure) drugs used to treat neuropathic (nerve) pain.

Gabapentinoids commonly prescribed in workers’ comp include:

Pregabalin (Lyrica®)

Gabapentin (Neurontin®)

Gabapentinoid Concerns

The clinical trials for pregabalin and gabapentin only included children/adolescents for partial-onset seizures and fibromyalgia – these trials did not establish safety and efficacy for the treatment of neuropathic pain in children/adolescents.8-9

Gabapentinoids present the same risks in younger individuals as they do in adults, but at a higher severity. This can include:

Mood alterations
Suicidal thoughts
Potential for abuse
Breathing difficulties

Research indicates that children may be at increased risks for adverse events. In a study of nearly 192,000 people from the Swedish Prescribed Drug Register who used gabapentinoids, increased hazards of all outcomes were associated with gabapentinoids for individuals aged 15-24.10

While gabapentinoid use should always be closely monitored, in the case of children it warrants additional attention.


For Gabapentinoids In Children / Adolescents

Clinical trials for gabapentinoids in the treatment of neuropathic pain did not include children/adolescents

Younger populations face the same adverse risks with gabapentinoids as adults, but at higher levels


Opioid pain medications that are often utilized in workers’ comp include:

Hydrocodone (Lortab®, Norco®, Vicodin®)

Hydromorphone (Dialudid®)

Tramadol (Ultram®, Ultram® ER)

Oxycodone (Oxycontin®, Xtampza® ER, Oxaydo®, Roxicodone®)

While opioid therapy can be effective in adult populations, it requires close monitoring, as even appropriate use can lead to dependence, addiction, and other adverse events. However, opioid-related concerns with adolescents are even greater.

Opioid Concerns

The Centers for Disease Control and Prevention's (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain notes that the available evidence concerning the benefits and risks of long-term opioid therapy in children and adolescents remains limited, and few opioid medications provide information in their labeling regarding safety and effectiveness in pediatric patients.11

According to the CDC guidelines, recommendations for the use of opioids as pain medications for children are only available for sickle cell disease, for children undergoing surgical procedures, and for palliative care in adolescent and young adult patients with cancer.11

Opioids may be utilized in limited treatment scenarios for adolescents, such as post-surgical pain. However, providers must seriously weigh benefits against elevated risks.

The risks associated with opioid therapy are well known within and beyond the workers’ comp industry due to the opioid epidemic. Opioid-related risks include:

Risk of physical dependence and addiction
Respiratory depression
Overdose and death
Harmful drug-drug and drug-disease interactions
Nausea, vomiting, constipation

These risks are present for all populations, however younger individuals may be more susceptible to certain opioid-related risks.

A systematic review of over 14,000 clinical articles found that a significant portion of adolescents with access to opioids misuse them.12 Prescriptions from a health care professional are the most common source of opioids for adolescents who misuse them, and of adolescents who misuse prescription opioids, a significant number will develop dependence or opioid use disorders.12

According to findings from Pediatrics, approximately 46% of pediatric opioid prescriptions – defined as prescriptions for individuals aged 0-21 years – are high risk.13

Opioid therapy should only be utilized in younger populations when the benefits outweigh the risks, which would be for particularly severe conditions.


For Opioids In Children / Adolescents

The CDC notes a lack of evidence concerning risks and benefits for long-term opioid therapy in children and adolescents

Few opioid medications provide information in their labeling on safety and efficacy in pediatric patients

46% of pediatric opioid prescriptions are high risk

Muscle Relaxants

Muscle relaxants are drugs used to alleviate muscle spasms and pain. Several muscle relaxants are Schedule IV drugs. Common muscle relaxants in workers comp include:

Baclofen (Lioresal®, Gablofen®)

Carisoprodol (Soma®)

Cyclobenzaprine (Amrix®, Fexmid®)

Diazepam (Valium®, Diastat®)

Methocarbamol (Robaxin®)

Muscle Relaxant Concerns

Muscle relaxants should only be used short-term, as they present risks such as:

Mood change and impaired thinking
CNS depression
Respiratory depression
Heart failure
Potential for addiction and abuse

Specific to adolescents, there is a lack of randomized control studies in the pediatric population regarding the use of muscle relaxants.14 However, muscle relaxants can be used as part of a multidisciplinary approach to treat musculoskeletal conditions.14

While all muscle relaxants share some of the same risks, different muscle relaxants possess different risks among adolescent populations.


For Muscle Relaxants In Children / Adolescents

There is a lack of randomized control studies in the pediatric population regarding the use of muscle relaxants

Different muscle relaxants possess different risks among adolescent populations

Specific Risks of Different Muscle Relaxants Among Adolescents



Can cause life-threatening withdrawal if not weaned effectively

Increases to blood sugar, which can be problematic in diabetic populations

Impacts to the liver and renal system, requiring the monitoring of liver function tests (LFTs) – this drug is contraindicated in severe renal impairment

Can precipitate bronchospasm and issues in those with asthma

Cardiovascular depression, contraindicating this drug among heart patients


High abuse potential – this drug is not often recommended in pediatric populations

Must be weaned to avoid withdrawal symptoms


Risk of overdose

Heart arrhythmia, which contraindicates this drug in heart patients

Blurred vision


Long-term use can lead to tolerance, abuse, withdrawal, and overdose


Can cause seizures

Uncontrollable rapid eye movement

Blurred vision


Ensuring an Effective Framework for Managing Unique Populations

As the factors impacting worker populations continue to evolve, so do the medical management needs of these populations – and workers’ comp medical programs must remain nimble to effectively address these shifting and unique needs.

Pharmacy management is but one component of managing unique patient populations but remains a significant one to help ensure that injured workers, regardless of their age, remain on the path to recovery in a safe and effective manner.

Key benefits that pharmacy management partners can offer for managing unique patient populations include flexible systems and processes that allow for customizable rules for different patient populations, and the expertise of on-staff clinical pharmacists who can provide unique pharmacotherapy insights that inform both program strategy and individual claims as needed.


  1. Desilver D. After dropping in 2020, teen summer employment may be poised to continue its slow comeback. Pew Research Center. June 21, 2022.
  2. Kelso A. Study: teens make up nearly a quarter of limited-service restaurant workforce. Restaurant Dive. Dec 2, 2021.
  3. Stephenson T. How children's responses to drugs differ from adults. Br J Clin Pharmacol. 2005 Jun;59(6):670-3. doi: 10.1111/j.1365-2125.2005.02445.x. PMID: 15948930; PMCID: PMC1884865.
  4. Alli RA. Treating pain in children. WebMD. June 1, 2021.
  5. Who can and cannot take low-dose aspirin. National Health Service (UK). Last reviewed Dec 16, 2021.
  6. Beutler AI, Chestnut GT, Mattingly JC. Aspirin Use in Children for Fever or Viral Syndromes. American Academy of Family Physicians. Dec 15, 2009.
  7. Shone LP, King JP, Doane C, et al. Misunderstanding and potential unintended misuse of acetaminophen among adolescents and young adults. J Health Commun. 2011;16 Suppl 3(Suppl 3):256-67. doi: 10.1080/10810730.2011.604384. PMID: 21951256; PMCID: PMC3791623.
  8. Lyrica (pregabalin) drug label. FDA. Dec 13, 2023.,022488s018,209501s005lbl.pdf
  9. Neurontin (gabapentin) drug label. FDA. Dec 16, 2020.,022488s018,209501s005lbl.pdf
  10. Molero Y, Larsson H, D’Onofrio BM, et al. Associations between gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime: population based cohort study in Sweden. BMJ 2019;365:l2147
  11. Dowell D, Ragan KR, Jones CM, et al. CDC clinical practice guideline for prescribing opioids for pain – United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI:
  12. Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg. 2021 Jan 1;156(1):76-90. doi: 10.1001/jamasurg.2020.5045
  13. Chua KP, Brummett CM, Conti RM, Bohner AS. Opioid prescribing to US children and young adults in 2019. Pediatrics (2021) 148 (3): e2021051539.
  14. Wong J, Chernishof V, Kim E. Muscle Relaxants in Pediatric Pain Management. Society for Pediatric Pain Medicine. 2020.


Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.