Published November 19, 2020
Editor’s note: Solutions for Kids in Pain (SKIP) is a national knowledge mobilization network, based at Dalhousie University and co-led by Children’s Healthcare Canada, that seeks to bridge the gap between current treatment practices and available evidence-based solutions for children’s pain in Canadian health institutions. The Canadian Foundation for Healthcare Improvement (CFHI) is a not-for-profit organization funded by Health Canada. CFHI works shoulder-to-shoulder with partners to accelerate the identification, spread and scale of proven healthcare innovations. The following article summarizes a recent webinar hosted by SKIP and CFHI on the topic of the use of opioids in children with acute pain.
Management of pain with prescription opioids is a subject of clinical and public concern, if not contention, at times. While many healthcare providers have expressed worry over the use of opioids to treat pain, many patients express unease that without access to these medications, they will not receive the adequate pain management they desperately need. These concerns are often amplified in the pediatric context, where children’s pain has been notoriously undertreated.
The apprehensions surrounding opioid use in kids, along with strategies for the future prescribing of opioids for pediatric acute pain (pain that is often, but not exclusively, associated with an injury, illness, or medical procedure), were the focus of a July 22, 2020, webinar hosted by SKIP and CFHI and moderated by Katie Birnie, of the University of Calgary, Canada, and Assistant Scientific Director of SKIP. Entitled Opioids and Our Children: Resources, Best Practices and Opportunities to Support Effective and Safe Prescribing and Use of Opioids for Acute Pain in Children & Youth, the discussion featured patient and family partners Isabel Jordan and Stephanie Paravan, who shared their perspectives on resources and strategies for supporting effective and safe opioid prescribing in kids, as well as Samina Ali, of the University of Alberta, Canada, and a SKIP Regional Hub Lead, who discussed best practices for opioid prescription and management for healthcare providers.
The use of opioids to manage acute pain in children is not without its challenges. However, through information sharing and appropriate support for families, opioid prescriptions can bring about safe and effective pain management for children.
Sharing information about opioids – what are the issues?
For many families, an episode of acute pain is one of the first times their children will receive a prescription for an opioid medication. But with this prescription comes a range of questions and concerns that may be shared by children and their caregivers.
There are best practice resources supported by scientific evidence to guide the prescription of opioid medications for pain management in children, such as Health Quality Ontario’s patient reference guide, Holland Bloorview Kids Rehabililtation Hospital’s opioid medication safety guide, and the Hospital for Sick Children’s safe opioid checklist for kids. As Jordan pointed out, however, information or resources had rarely ever been provided to her or her child, who received a prescription for opioids for pain management. Interestingly, she noted, she had never even seen a patient resource on opioids until she was approached to review resources and asked to give her thoughts on a few that are now available. Jordan noted, however, that she was only made aware of these resources through her role as a patient and family partner, which involves sharing lived experiences of having a chronic illness in the family to help shape research and resource development.
Jordan’s experience suggests a problematic breakdown in information sharing between healthcare providers and families. Despite concerns that patients and families do not understand how to use opioids appropriately, families are not routinely provided with accessible, evidence-based information on how to do so. Both Jordan and Paravan recall receiving insufficient resources and information for their children’s pain management, which left them with many questions about how to manage their children’s pain.
“We had questions about opioid use,” Jordan said. “Would my child get addicted? Was this dangerous? How do you explain his use of opioids to family? To him? To the other healthcare providers in the ER? How do you put the use of opioids for his current new pain in the context of his many other symptoms that we manage for his rare disease? How do we manage side effects?” Jordan concluded that “the answers to these questions [were] a void.”
Jordan’s questions extended beyond the pharmacological, or medicinal, properties of opioids prescribed for her child to include questions about who was responsible for coordinating her child’s opioid management. Jordan highlighted this confusion when discussing the available resources, saying that “some of them say to contact your medical team, but they don’t say who that might be or who the best clinician would be to contact about those kinds of issues.” Both patient and family partners agreed that there is much work to be done to promote better information sharing so families can use opioids effectively and safely, work that is being undertaken by organizations such as SKIP.
Not enough information means a lost opportunity
Insufficient information about opioid medications may influence a child or caregiver’s decision to pursue opioid treatment, which in turn could mean that children may not receive appropriate pain management. Paravan discussed her child’s own fear around taking opioids to manage pain, influenced greatly by knowledge about the risky side effects, with limited knowledge of the benefits. A few trials of different opioid medications were also required, which is another aspect of opioid treatment many families may not be aware of.
As Paravan emphasized, the benefits of opioid medications can be life changing, as they were for her child, but the benefits are not often part of the dialogue around opioids, especially in the public sphere. Paravan highlighted the importance of sharing the benefits of opioid medications in addition to the risks, as well as information on what else families can expect in the phases of trying various medications.
“He’d seen the commercials about fentanyl. He’d heard about what happens to kids on fentanyl in the news and he was terrified that trying a fentanyl patch would mean a certain death. Once [fentanyl] was explained to him and we started trying the opioids, we saw a difference in Matthew’s pain. It wasn’t an easy road, we had to try many different medications…some of the side effects were terrible…but we finally found the right combination: a multimodal approach of using medication, procedures, and physiotherapy. There was a total change in him…we hadn’t seen him smile for more than two years,” said Paravan.
What was very apparent from both Paravan and Jordan was that without sufficient information about both the risks and benefits of opioid medications, as well as about other questions related to the use of these medications, it is difficult to make fully informed decisions about treatment. In turn, patients, families, and caregivers may unnecessarily avoid opioids, lacking the full picture of how these medications can help kids.
When it comes to communicating about opioids, Jordan stressed the importance of having information for families in the form of resources, while Paravan also said having a knowledgeable health care team to help navigate decisions around opioid use and complementary forms of pain management is critical. By having information at the fingertips of parents and children, in conjunction with well-informed healthcare providers who can provide guidance on decision making, families will have the support they need to make decisions around their child’s use of opioids.
Jordan and Paravan also highlighted the need to know who opioids might be appropriate for and how they can be used alongside other treatments. For example, Paravan described how her child benefited from multimodal care, which refers to a combination of therapies (such as medication and physical therapy) to manage pain in the long term. However, if children and families do not understand what their options are or how these different approaches can work together, the possibility for exploring treatments that complement opioids may be overlooked.
What resources are available?
Samina Ali continued the discussion by sharing key considerations and resources for healthcare providers. She highlighted many resources that healthcare providers can access such as evidence summaries as well as clinical guidelines, which make recommendations for best prescribing practices based on the existing scientific evidence. For example, the Alberta Dental Association and College has developed the Guide for Pain Management/Opioids for decisions around opioid prescriptions for pain management in dental practice. Resources such as these provide a quick reference for healthcare providers to make evidence-based decisions when working with pediatric patients. Safety bulletins, which consolidate available research evidence and safety recommendations, are also available through organizations such as the Institute for Safe Medication Practices Canada.
Ali further highlighted that healthcare providers can also benefit from education now available about pain and pain management. For example, the Hospital for Sick Children in Toronto has developed the Online Pediatric Pain Curriculum program for healthcare providers, which provides education about pain in a clinical, scientific, and ethical context. Such resources help healthcare providers engage with evidence on pain management in an educational context, and they are freely available, evidence-based, and may be a step toward common approaches to pain management that are medically and ethically sound.
Ali explained that physicians often have access to different resources and information, meaning that different recommendations may be provided depending on where the physician looks. Variation in resources may be problematic in some contexts, as it can introduce inconsistent pain management practices between health centers or individual healthcare providers.
“As clinicians and healthcare providers, we don’t all have the same access to information and then, in some cases, there are gaps or missing information,” said Ali.
What is key, however, is that the resources available to healthcare providers, such as those described above, combine all best practices. This can result in consistency in the recommendations given to all healthcare providers when it comes to opioid prescriptions. In working towards this goal of consistency and availability of resources, SKIP has provided an executive summary that provides an overview of available health resources on opioids, including the ones mentioned above, to support healthcare providers in opioid prescribing.
Thanks to the collection of patient and family experiences shared by Jordan and Paravan, along with Ali’s perspective as a researcher and healthcare provider, and input from the webinar audience, there was a constructive discussion about how to share resources and implement best practices for improved opioid prescribing for acute pain in kids. For example, some participants discussed the importance of engaging pharmacists, who can work alongside care teams and families to coordinate care and support families who have questions about the use of opioids.
Others discussed the value of the opportunity to bridge pain care from hospital to home, and providing virtual care appointments to ensure families remain connected with the care team to answer questions. Participants also discussed the importance of clarity around resources, with many calls for clear printed resources not only on medications, but on other therapies that could complement opioid treatment.
One of the key messages expressed by Birnie was the importance of collaboration between healthcare providers, families, and researchers when it comes to developing resources and practice recommendations. Specifically, including patient and family partners with lived experience of pain in research and in resource development is critical to ensure that resources on opioid use are accessible and useful.
“How can we collaborate and coordinate and really build on this synergy and energy? What we make coming out of that…is to partner with children, youth, caregivers, and healthcare providers to inform creation and sharing of resources, and to spread best practices,” Birnie said.
Participants also pointed to bias and stigma, often brought about by healthcare providers, as barriers to appropriate use of opioids. Collaboration with patient and family partners could address these problems through the creation of resources that dispel commonly held misconceptions that impede safe and effective opioid use. Given the life-changing effects these medications can have in children, and the discord in the medical community and society at large with regard to opioid use, involving patient and family partners in these discussions is more important than ever.
The ultimate goal is to see change at the highest levels of healthcare institutions and in health policy, to ensure that the use of best practices for opioid prescriptions is well supported and well managed, while also empowering patients, families, and caregivers to ask questions. As Birnie said, it is strong partnership, collaboration and constructive dialogue between healthcare providers, children and caregivers, and researchers that will spur progress and ensure that opioids are used safely and effectively for children’s acute pain.
Nicole MacKenzie is a PhD student at Dalhousie University, Halifax, Canada.