No one should experience untreated pain. Yet, in Canada, two out of three children undergo painful procedures without any pain management, and one in five experience pain that lasts months to years. Health Canada’s 2021 ‘Action Plan for Pain in Canada’ recognized children as a population disproportionately impacted by pain. Poorly managed pain hurts children in the moment and has life-long consequences across all areas of life, including their physical, mental, and social well-being.

Unfortunately, Canada is also in the midst of an opioid crisis, with a particularly detrimental impact on youth, who are the fastest growing age demographic requiring hospitalization from opioid overdose. The undertreatment of pain is a major contributor to the opioid crisis, and pain relief is a primary reason for opioid prescribing, long-term opioid use, non-prescription opioid use, and opioid use disorder amongst youth. Opioids prescribed for pain in youth, and poorly managed pain, can start a cascade of opioid use that persists into adulthood.

At the same time, opioids are recognized as an appropriate and important part of pain management, particularly for moderate to severe short-term pain and when other pain treatments are inadequate. Although opioids should not be considered the first choice for pain relief in children, they are safe and effective when used correctly. However, there is a lack of evidence-based guidelines for opioid prescribing for pain in youth, driving an urgent need to bridge the knowledge gap between treatment practices and evidence-based solutions.

We have learned a lot about how to effectively and safely prescribe opioids to help treat pain. While not necessary in all cases, many youth, including the most vulnerable, need these medications to live normal lives. Explaining to youth and families why opioids can be helpful and how they can be safely used is critical to delivering high-quality care. 

In October 2022, Solutions for Kids in Pain (SKIP), a national knowledge mobilization network promoting evidence-based solutions for children’s pain, launched “Youth in Pain: Solutions for Effective Opioid Use”. This 18-month project funded by Health Canada mobilized solutions for effective, safe, and equitable use of opioids for pain management in youth. SKIP led this work in partnership with a 16 member national advisory group, 86 patient and parent partners or advisors, and 38 organizational partners (including the Canadian Centre for Substance Use and Addiction, the Canadian Dental Association, the Sickle Cell Awareness Group of Ontario, and the Institute for Safe Medication Practices, among others).

The project co-developed over 30 tools, resources, and activities in English and in French with and for youth, families, health professionals, and decisionmakers. These include interactive educational modules, factsheets, conversation guides, an evidence-based toolkit, media articles, information and implementation documents for health professionals, patients, and caregivers, and a narrative change campaign launched during National Pain Awareness Week in November 2023 that reached more than 9 million views (#ItDoesntHaveToHurt #NPAW2023).

The project shares best-available evidence and guidance for the use of opioids for acute and chronic pain for youth, and emphasize a multimodal and de-stigmatized approach to pain management that combines physical, psychosocial, and pharmacological strategies. This aligns with guidance in Canada’s first national health standard for Pediatric Pain Management (CAN/HSO 13200:2023) published in 2023 by the Health Standards Organization in partnership with SKIP. The Pediatric Pain Management standard guides organizational leaders and healthcare teams how to deliver quality, equitable acute and chronic pain care for children from birth to 18 years old in all hospital settings.

Health professionals and decisionmakers should work together to create an environment where evidence-based approaches for pain management, including the use of opioids when appropriate, are considered without judgment.  

Partly due to the immense burden of the ongoing opioid crisis, there has been growing concern from prescribers, patients, policymakers, and the media about the societal and health risks associated with opioid use, especially amongst youth. In many instances, stigma around the use of opioids co-occurs with widespread stigmatization of pain itself.

“Living with pain means that a lot of my struggle is invisible and can make it hard to understand by others. That lack of recognition only pushed me further to believe that my comfort and wellbeing was not prioritized, instead it was being invalidated,” adds Sabrina Cannella, a youth living with chronic pain. “I was incredibly reluctant to state I had pain in fear of being labelled as ‘drug seeking’, I equally hesitated to describe the benefits I felt from the opioid medications to avoid being labeled with substance use disorder. The conversation would shift from creating a care plan to treat my pain in the best way possible, to a plan that carried the least stigma or the least risks. I no longer felt like pain control was amongst the goals of my care team but instead a plan to cater to the stigma of opioids”.

There is a need for resources that address both pain- and opioid-related stigma in youth with pain. Opioids should never be withheld in situations where they are clinically indicated or warranted, and health professionals need to remain mindful of biases when deciding whether to prescribe opioids, such as those related to race, gender, and/or socioeconomic status. To address intersecting stigma and racism, SKIP’s Youth in Pain project prioritized the development of resources for specific populations such as youth with sickle cell disease, for whom access to opioids are an important part of quality pain care.

Invest time to talk to youth and families about their pain. It helps to ensure they feel heard and cared for, reduces stigma around pain and its treatments, and increases the likelihood of engagement in care. 

Open communication between youth, families, and health professionals is helpful to understand how pain works and identify the best solutions. As highlighted by Sabrina, “I finally felt on solid ground when my team and I met in the middle. I know that my pain will never be 100% resolved with opioids alone, or anything for that matter. Instead we created a tool box that was composed of multiple methods to address the pain cohesively. It no longer felt as though I was doing something wrong by finding relief in high risk medications like opioids.”

Access to effective pain management for all children is more than just a human right; it is critical to address the intersecting public health crises related to pain, opioids, and mental health – especially amongst Canada’s children and youth.

It is clear there is a sustained need for conversations that prioritize quality pain care for youth, and the role of opioids as part of multimodal pain care. SKIP’s Youth in Pain project begins to fill that gap by raising awareness and promoting use of evidence-based solutions. We call on others to also ensure that equitable, comprehensive, and effective pain management is integrated into all relevant child health policies and strategies as essential to support youth, their families, and health professionals in Canada.

SKIP’s vision is healthier Canadians through better pain management for children. Visit www.kidsinpain.ca/youth-in-pain or follow @kidsinpain. This article has been made 2possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.