Objective In recent years, there has been increased emphasis on treating pain in emergency departments (EDs), coinciding with mounting concerns regarding the abuse potential of prescription opioids. In this study, we describe trends in opioid prescribing in pediatric patients in the US EDs over the past decade. Methods Data from the 2001-2010 National Hospital Ambulatory Medical Care Survey were analyzed and pain-related visits were identified. Pain-related ED visits by pediatric patients (19 y) where an opioid analgesic was administered or prescribed were tabulated by age category and year. Specific opioids analyzed included codeine, hydrocodone, hydromorphone, morphine, and oxycodone. The use patterns of nonopioid pain relievers were also investigated. Results were further stratified by Drug Enforcement Agency schedule and pain-related diagnosis. Results The overall use of opioid analgesics in pain-related pediatric ED visits increased from 11.2% to 14.5% between 2001 and 2010 (P = 0.015). The use of Drug Enforcement Agency schedule II agents doubled from 3.6% in 2001 to 7.0% in 2010 (P < 0.001), whereas there was no significant increase in the use of schedule III, IV, and V agents (P = 0.34). Hydrocodone was the most frequently prescribed opioid analgesic. Increased opioid use was most dramatic in ED visits that involved adolescents. There was no significant increase in the use of nonopioid analgesics in pediatric ED patients (P = 0.086). Conclusions Opioid use for pain-related pediatric ED visits has increased significantly from 2001 to 2010, particularly among adolescents. Emergency department providers must be vigilant in balancing pain relief with minimizing the adverse effects of opioid analgesics.