The pendulum may have swung too far in the direction of caution when it comes to limiting opioids for adolescents who are in pain, according to new research from a University of Alberta emergency medicine team.
The investigators sought to examine a long-held belief by clinicians and parents that an opioid prescription for pain from a torn muscle or broken limb could put a teenager at higher risk for future opioid-related harms such as overdose or addiction.
“You feel this hesitancy about prescribing opioids because it’s been drilled into us from the media that opioid prescriptions are why we have the opioid crisis,” says study lead Dr. Henry Li, an emergency physician at the University of Alberta Hospital and pediatric emergency medicine fellow at the Stollery Children’s Hospital.
“On every shift, we see how the opioid crisis is impacting the patients that we serve, and we really don't want to be contributing to that.”
The team tracked population-level data for nearly 1.2 million emergency department visits by Alberta 12 to 17-year-olds between 2010 and 2020. They assessed trends in opioid prescribing, and then looked to see how those numbers compared with signals of opioid-related harms in the same population — events like emergency department visits or hospital admissions for opioid withdrawal or overdose, or starting a prescription for an opioid abuse disorder treatment such as methadone or suboxone.
They found that opioid prescriptions decreased from 3.3 per cent of visits in 2010 to 1.2 per cent in 2020.
Over the same time period, the development of opioid-related harms in this age group rose from 0.15 per cent in 2010 to 0.28 per cent in 2020, suggesting “that emergency department opioid prescriptions may not be a significant driver of the opioid epidemic for youth, and that we should not shy away from using opioids to treat adolescents who are in pain when other medications are not working.”
While the numbers are small, a doubling of opioid-related harms among teens over a decade is concerning, but today’s opioid crisis is driven by contaminants in the supply of illicit fentanyl, carfentanil and other street drugs, rather than the overprescribing and aggressive marketing to doctors that were to blame in the 1990s and early 2000s, Li notes.
Li hopes the study results will ease the concerns of parents who have resisted opioid prescriptions for their children because they are so worried their teens might get hooked.
“I've had instances where patients are still in quite a bit of pain even after taking their acetaminophen and ibuprofen, and yet the next steps, including using opioids, are very much resisted by their parents because they don't want any chance at all of this potentially leading to opiate harms for their child,” he says.
“If your child is in pain and the other things that we've tried to reduce that pain have not worked, it’s still very reasonable to try a limited dose of opioids to see if they will help.”
This finding builds on another University of Alberta-led paper called the No OUCH study, reported earlier this year, which noted that opioids are often not needed as a first resort.
“Their study found that as a first-line treatment for a musculoskeletal injury we should not be reaching for opioids, we should be using Ibuprofen first,” Li explains. “The key message combining the two studies together is that there may be a time and a place for both.”
The research team will next try to quantify the individual risks for teens taking opioids by doing a comparative study looking at outcomes for patients with specific factors such as age, sex, gender, socioeconomic status and presenting illness.
“We know from existing studies that certain groups of patients, especially those who have mental health disorders or substance use disorders, experience greater risks for developing opioid harms,” Li says.
“It’s very helpful clinically when I’m talking to families to be able to say, ‘This may increase the risk of this type of complication by x per cent,’ so we’d like to provide some hard data to really support providers and patients and their families in making that decision.”
This research was funded by the Canadian Institutes of Health Research, with support from the U of A’s Data Analytics Research Core and the Alberta SPOR SUPPORT Unit. Li is part of the Pragmatic Trials Training Program and serves on the executive/steering committees of Pediatric Emergency Research Canada, Translating Emergency Knowledge for Kids, and the Canadian Association of Emergency Physicians Digital Emergency Medicine Committee.
