McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Cluster 4: Treating Specific Populations with LTOT

R18. Recommendation Statement

No. Recommendation Keyword
R18 Opioids present hazards for adolescents (Grade B). A trial of opioid therapy may be considered for adolescent patients with well-defined somatic or neuropathic pain conditions when non-opioid alternatives have failed, risk of opioid misuse is assessed as low, close monitoring is available, and consultation, if feasible, is included in the treatment plan (Grade C). Adolescent patients
  • R18. Discussion
  • R18. Summary of Peer-Reviewed Evidence

R18. Discussion

1. Opioids Hazardous for Adolescents

Non-medical use (misuse) of opioids is more common among adolescents, and may be a risk factor for future opioid addiction. Among adolescents, risk factors for opioid misuse include poor academic performance; higher risk-taking levels; major depression; and regular use of alcohol, cannabis, and nicotine (Schepis 2008).

Misuse and overdose are the greatest risks for adolescents. To reduce these risks:

  • Educate the patient and family: Explain the risks of abuse and overdose carefully to the patient and (if feasible) the family. Emphasize the risks of taking extra doses or giving opioids to friends.
  • Whenever feasible, seek consultation with a healthcare provider experienced in treating adolescents (e.g., social worker, pediatrician, psychiatrist, psychologist, physician with expertise in pain management and/or addictions) before placing an adolescent on LTOT.

2. Prescribing Cautions for Adolescents

  • Titrate more slowly; try to avoid opioids that are commonly abused in the local community.
  • Avoid benzodiazepines if possible.
  • Use structured opioid therapy (see Recommendation 21), with a specific treatment agreement, conservative dosing, frequent dispensing, monitoring for aberrant behaviours, and urine drug screening.
  • Consider tapering the opioid if the patient does not experience opioid effectiveness: improved function or at least 30% reduction in pain intensity. See Appendix B-12 for a tapering protocol.

R17. Summary of Peer-Reviewed Evidence

1. Non-medical use of opioids is common among adolescents, and may be a risk factor for future opioid addiction.

In 2007, researchers from the Centre for Addiction and Mental Health in Toronto ON released the "Ontario Student Drug Use and Health Survey." They found that 21% of Ontario students in grades 7 to 12 report using prescription opioid pain relievers such as Tylenol® No. 3 and Percocet® for non-medical purposes; almost 72% report obtaining the drugs from home. In addition, among all drugs asked about, OxyContin® was the only drug to show a significant, but small, increase in non-medical use since the last survey (2% of students reported using it in 2007, representing about 18,100 students, compared to 1% in 2005) (Adlaf 2006).

One study from Michigan documented that 12% of high-school students had used opioids in the past year  (Boyd 2006). Another study documented that the risk of developing prescription drug abuse and dependence later is correlated with the age of first exposure to opioids (McCabe 2007).

Among adolescents, risk factors for opioid misuse include poor academic performance; higher risk-taking levels; major depression; and regular use of alcohol, cannabis, and nicotine (Schepis 2008).