Prescribing Guidelines, More Research on Addiction Potential Needed for Use of Opioids to Treat Children’s Pain
A pair of new studies led by University of Alberta pediatricians indicate that parents are more reluctant to have opioids prescribed for their children than doctors are to prescribe them.
In a study published this week, the researchers asked 136 pediatric emergency room doctors across Canada whether concerns about potential addiction or the opioid crisis hold them back from prescribing opioids such as fentanyl and morphine to children with moderate to severe pain.
The doctors reported minimal concern, although they did say that parental reluctance, a lack of guidelines for opioid use in children and concern about side-effects play a role in their approach to prescribing opioids to children. Both the World Health Organization and the American Academy of Pediatrics recommend prescribing opioids for children with moderate to severe pain that does not respond to non-opioid medication, such as acetaminophen or ibuprofen.
In a separate study published recently, U of A researchers asked more than 500 parents and caregivers about their willingness to accept an opioid prescription for their child.
Only half said they would accept opioids for moderate pain and only 33 per cent would accept them for at-home use. The parents cited fears of addiction, side-effects and overdose.
“Right now we don’t have a lot of strong evidence to say how worried we should be about addiction risk of opioids for children,” said lead author Megan Fowler, an emergency physician at Edmonton's Stollery Children’s Hospital and clinical lecturer in pediatrics at the U of A.
“We do know that treating children’s pain is very important, so physicians do have to prescribe opioids responsibly,” Fowler said. “More research and guidelines are going to be needed.”
Samina Ali, a U of A professor of pediatrics and adjunct professor of emergency medicine, as well as a pediatric emergency physician at the Stollery, said one in five children in North America are prescribed opioids by the time they are in their teens, usually to treat short-term pain from injuries or acute illnesses such as appendicitis.
She said parental fears are likely shaped by media reports about the opioid crisis, which point to inappropriate emergency room prescriptions as part of the problem. At the same time, physicians must follow their training, which directs them to do what they can to treat children’s pain.
“We know for a fact that not treating children’s pain has consequences,” Ali said. ”Short term, it makes investigation, diagnosis and getting kids home more difficult. Long term, there is a subset of children who develop true phobias of medical procedures, or they develop chronic pain disorders because their acute pain was not treated adequately.”
Balancing Known and Unknown Risks
Ali said doctors must balance the unknown risks of opioid treatment with the known risks of untreated pain.
“That’s why they will still offer opioids in small amounts when pain is severe, and only as needed,” she said.
Her message to doctors is, “Don't stop prescribing. Prescribe in the most responsible of ways based on the evidence. And where evidence is lacking, our research teams will try to address that.”
Ali said a number of steps need to be taken to gather more information for both parents and physicians about the impact of opioids on children.
Her team is working with the Alberta Research Center for Health Evidence on a systematic review of research evidence to determine whether there is a link between short-term opioid use for medical reasons and the potential to develop addiction later in life.
“We know that being exposed to opioids as a child increases your risk of having an opioid use disorder, but there is very little research linking short-term use to long-term outcomes,” she said. “We need to know more about that.”
The U of A team is conducting in-depth interviews with some of the physicians surveyed to better understand their thought process when prescribing opioids to children.
They are also working with a federally funded initiative called Solutions for Kids in Pain to better disseminate evidence about how to treat children’s pain.
“In response to the opioid crisis, the Government of Canada has published guidelines for prescribing opioids to adults, but there is nothing for children,” said Fowler. “Pediatric physicians are kind of left empty-handed.”
Looking for Effective Alternatives
Ali said even without the concerns about addiction, half of patients who are prescribed opioids will get some combination of side-effects including sleepiness, dizziness, constipation, stomach pain and nausea.
“None of that is pleasant when you’re already feeling sick or injured,” Ali said.
The U of A team is exploring alternatives to opioids for treating pain in children, including the No-Ouch Study, which compares the effectiveness of ibuprofen on its own with a combination of ibuprofen and acetaminophen, and another combination of ibuprofen and hydromorphone, an opioid.
Ali encouraged health-care professionals and parents to always use non-medicinal comforts for children who are in pain.
“If I have a broken arm, it should be in a splint, which will probably take away a third or a half of the pain if I just stop moving it for a few days,” Ali said. “And then I put ice on it and that takes down inflammation. And then some nice person makes me a cup of tea and puts on Netflix, and now I’m distracted and feel cared for, and so my perception of pain goes down.
“My arm is still broken, and I will likely still need pain medications, but likely a whole lot less than if these things were not provided,” Ali explained. “Pain is so complicated.”
The studies on pediatric physician and parental concerns about opioid use were funded by the Stollery Children’s Hospital Foundation through the Women and Children's Health Research Institute.