Intersection of the pain crisis and the opioid crisis
In an effort to better manage pain, opioid prescribing surged in the 1990s and 2000s. This surge coincided with widespread use and misuse, culminating in what is referred to today as the opioid crisis. It is critical to distinguish between rates of opioid related deaths as a result of illicit opioid use (e.g. fentanyl, carfentanil), which are increasing, while rates of opioid prescribing are actually declining.
Though recent attention about the use of opioids has focused on the potential negative outcomes, the reality is opioids are indispensable for the treatment of moderate to severe pain, especially in the acute pain, cancer pain and end of life settings. As health-care providers it is important that we balance our ethical responsibility to treat pain, with a societal responsibility to rationalize and optimize the use of opioids when appropriate.
Preventing and minimizing pain is a priority for children, and a critically important component of patient care. To dismiss the value of using opioids responsibly would reduce the resources we have to effectively manage pain in many of our patients. Rather than dismiss opioids as a valuable option for managing pain, we suggest that we embrace their ability to support positive outcomes in patient care while honouring our obligation to do so with parameters in place that protect patients from opioid-related harm.
Decision-making principles for prescribing opioids
Patients for whom opioids are being considered should first undergo a comprehensive pain assessment. Steps should then be taken to minimize the use of opioids using a combination of non-opioid pharmacotherapy together with physical and psychological strategies. If following these steps, pain management remains inadequate, providers need to acknowledge the value of opioid treatment and create a responsible plan of care ensuring they have the knowledge, skill and judgment to support patients in safe and effective opioid use.
Once a decision to prescribe opioids has been made the principles underpinning their use is similar for all treatment protocols.
These principles include the:
- safe initiation of opioid therapy
- choice of most appropriate opioid (e.g. lowest potency)
- dose titration (e.g. start low, go slow)
- use for shortest duration necessary
- avoidance of long-acting opioids
- monitoring of safety and effectiveness
To ensure successful outcomes of opioid treatment when managing pain, all patients (along with their families) should be provided with opioid related education, and have a plan in place for how to taper and cease opioids when they are no longer required, or if deemed ineffective or unsafe. Care should be taken in managing exacerbations of pain for patients who regularly take opioids, and also for those taking opioid replacement therapy for opioid use disorder.
Despite evidence-based pain management and clinical standards, moderate to severe pain in hospitalized children is common. Treating this pain is a critical component of patient care and if not managed effectively can have long term impact on the health and well-being of the patient. Inadequate acute pain management is harmful, in that it contributes to poor health outcomes, increased opioid use, and can lead to the development of chronic pain. In fact, at least 20 per cent of the paediatric population have chronic non-cancer pain; of whom 5 per cent have a disability with significant impact on health-related quality of life. Successful pain management requires regular monitoring and treatment of pain during hospitalization and after hospital discharge. Opioids can play an important role in a patient’s care and management of pain.
What is needed to improve pain prevention and treatment
- Better prevention and treatment of acute pain – there is evidence that acute pain increases the risk of chronic pain in adults and children
- Better access to interprofessional pain care – including chronic pain management facilities, access to psychologists and rehabilitation therapists
- Better pain education – veterinarians get 5 times more pain training than medical students
- Pain related research
Drs. Fiona Campbell and Lisa Isaac are staff anesthesiologists at SickKids.