June 12 Ministerial Opioid Roundtable
Hon. Jane Philpott, PC, MP, MD
Federal Minister of Health
House of Commons
6 June 2017
Dear Minister Philpott,
On behalf of the Canadian Association of Paediatric Health Centres and ChildKind International, we thank you for addressing the important topic of safe and effective healthcare for all. As you begin the dialogue at the Ministerial Roundtable on Opioids on Monday June 12th, 2017, we would ask that you consider the unique needs of Canada’s children and youth in the development of a national framework and pursuant recommendations. As a family physician, we know that you will recognize the role for and necessity of an advocate for children and youth throughout these deliberations.
The current opioid crisis in Canada has resulted in significant attention directed toward the prescribing and use of opioid medications. [i] Almost all this attention, however, is focused on the adult population. Similarly, and regretfully, the recently published and Health Canada sponsored 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain did not include any considerations or recommendations for children and youth. [ii] In Canadian paediatric medicine, opioids are generally used appropriately for acute or persistent tissue injury pain, including pain associated with childhood cancers. There is conflicting evidence whether the appropriate use of opioids for acute pain in children and youth can result in an increase in the incidence of opioid use disorders.[iii] [iv] However, we do know that significant treatment gaps remain, and many children suffer from un- or under-treated pain, which also has long term adverse consequences. We would like to see the Canadian government acknowledge that the risk for opioid addiction and misuse in childhood is not clearly understood, and in turn, prioritize the study of safer and effective pain management options for children. These options include psychological techniques, physiotherapy, other physical interventions, as well as both opioid and non-opioid pharmacological interventions.
While the clinical and research community generally works diligently to address children’s pain with non-opioid options and/or opioid-sparing regimes (ie combining non-opioid with opioid therapy, using psychological and physical interventions in addition to medications),[v] [vi] [vii] some children will ultimately require opioid use, either for the short or long term. Opioid prescriptions in children have more than doubled in the past decade, particularly related to short-term pain or a procedure.[viii] In parallel, caregiver and clinician concerns surrounding opioid use in children are mounting[ix] [x] as are reports of adverse outcomes[xi] And yet, health care providers, many of whom do not treat children or pain regularly, find themselves in the awkward and dangerous position of lacking clear nationally-endorsed guidelines for the treatment of such pain. Considering developmental differences, ontogeny, and dependence on another to assess and treat pain, national guidelines created for adults cannot be extrapolated to children. It is very important to focus on appropriate care and the development of programs and guidelines that can improve the lives of children.
The Canadian Association of Paediatric Health Centres (CAPHC) is a recognized leader and advocate for advancing the improvement of healthcare for Canada’s children and youth. CAPHC’s mandate is to affect system-wide change in the delivery of healthcare services. CAPHC focuses on innovative initiatives and programs that have broad national relevance, which are both practical and actionable at the point of service delivery. Over the past many years, CAPHC has demonstrated that advancing quality improvement in child and youth healthcare at a system level is possible through strength in collaboration, strategic partnerships and innovation.
Childkind International recognizes healthcare facilities that have developed standardized, institution-wide, collaborative approaches to the treatment of children’s pain, by certifying those institutions as ChildKind Certified Hospitals.
In 2014, CAPHC established a Pain Community of Practice to positively impact pain care for children across Canada, in all settings. It is comprised of a multi-disciplinary team of nurses, nurse practitioners, physicians, researchers, psychologists, child life specialists, policy makers, knowledge brokers, and others, from across the nation. This group of dedicated individuals is working with other national organizations (e.g. Canadian Paediatric Society, TREKK.ca) to facilitate the translation of knowledge and implementation of change to better pain management for children.
Our organizations would like to offer our assistance to you, in any way that you see fit, in making sure that children’s interests are heard and addressed in national policy regarding health and wellness.
In summary, CAPHC strongly believes that any national recommendation or guidelines to address the responsible use of opioids must include clear and explicit direction for the treatment of children. Without this, we risk non-uniform, potentially ill-informed, and possibly dangerous practice variation. We hope that you can agree this is not an outcome to which we strive.
President and CEO
Canadian Association of Paediatric Health Centres (CAPHC)
G. Allen Finley, MD FRCPC FAAP
Professor of Anesthesia & Psychology, Dalhousie University , Dr. Stewart Wenning Chair in Pediatric Pain, IWK Health Centre
Board Chair, ChildKind International
Samina Ali, MDCM, FRCPC(PEM)
Professor, Pediatrics & Emergency Medicine Faculty of Medicine & Dentistry, University of Alberta
Co-Chair CAPHC Pain Community of Practice
Ashleigh Townley, BSc, MA
Knowledge Broker, Evidence to Care Holland Bloorview Kids Rehabilitation Hospital
Co-Chair CAPHC Pain Community of Practice
This letter is also endorsed by the following national organizations that support the health and well-being of Canada’s children and youth.
Nicola L. Jones, MD, FRCPC, PhD
Principal Investigator and Director
Canadian Child Health Clinician Scientist Program
Mr. Frank Gavin
Canadian Family Advisory Network
Marie Adele Davis
Canadian Paediatric Society
Anne Junker, MD, FRCPC
Maternal, Infant, Child and Youth Research Network
Allison Eddy MD
Paediatric Chairs of Canada
Helene Flageole MD, MSc, FRCSC, FACS
Chair, Pediatric Surgical Chiefs of Canada
Christine Hampson Ph.D.
President & CEO
The Sandbox Project
[iii] McCabe SE, Veliz P, Schulenberg JE. Adolescent context of exposure to prescription opioids and substance use disorder symptoms at age 35: A national longitudinal study. Pain 2016;157(10):2173-8
[iv] Pediatrics. 2015 Nov;136(5):e1169-77. doi: 10.1542/peds.2015-1364. Prescription Opioids in Adolescence and Future Opioid Misuse. Miech R1, Johnston L2, O'Malley PM2, Keyes KM3, Heard K4
[v] How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review. Hartling L, Ali S, Dryden DM, Chordiya P, Johnson DW, Plint AC, Stang A, McGrath PJ, Drendel AL. Pain Res Manag. 2016;2016:5346819. doi: 10.1155/2016/5346819. Epub 2016 Dec 18. Review. PMID: 28077923
[vi] Pediatric Pain Management in the Emergency Department: The Triage Nurses' Perspective. Thomas D, Kircher J, Plint AC, Fitzpatrick E, Newton AS, Rosychuk RJ, Grewal S, Ali S. J Emerg Nurs. 2015 Sep;41(5):407-13. doi: 10.1016/j.jen.2015.02.012. Epub 2015 Mar 31. PMID: 25837698
[vii] Acute pediatric musculoskeletal pain management in North America: a practice variation survey. Kircher J, Drendel AL, Newton AS, Plint AC, Vandermeer B, Dulai S, Ali S. Clin Pediatr (Phila). 2014 Dec;53(14):1326-35. doi: 10.1177/0009922814555972. PMID: 25381329
[viii] . Fortuna RJ, R.B., Caiola E, Joynt M, Halterman JS, Prescribing of controlled medications to adolescents and young adults in the United States. . Pediatrics, 2010. 126(6): p. 1108-1116
[ix] Basco WT, A.K. Are We Overprescribing Opioids for Pediatric Pain? [Internet] 2016 December 20, 2016 [cited 2017 January 12]; Available from: http://www.medscape.com/viewarticle/873283
[x] Miech, R., et al., Prescription Opioids in Adolescence and Future Opioid Misuse. PEDIATRICS, 2015. 136(5): p. E1169-E1177.
[xi] Kelly, L.E., et al., Morphine or Ibuprofen for post-tonsillectomy analgesia: a randomized trial. Pediatrics, 2015. 135(2): p. 307-313.