pediatric opioid use and misuse · pediatric poisoning in a study in 2011, the most common cause of...

PEDIATRIC OPIOID USE AND MISUSE

Loma Linda University Pediatrics Project AdvocacyMarti Baum, MD Alyssa Dann, MD

OBJECTIVES/OVERVIEW

➤ Pediatric Opioid Poisoning

➤ Non‐Medical Use of Opioids in Children and Adolescents

➤ Post‐operative and Prescription Opioid Use

➤ In‐utero Opioid Exposure and Neonatal Abstinence Syndrome

➤ Sports and Opioids

➤ Opioid Addiction and Treatment Options

➤ Safe Prescribing Practices and Opioid Monitoring Strategies

PEDIATRIC POISONING➤ This study evaluated risk factors for unintentional opioid overdose or

poisoning in young children and nonmedical/intentional use or overdose in adolescents.

➤ Efforts already implemented to decrease incidence of poisoning include child‐safe packaging.

➤ Safe storage defined as locked or latched for younger kids, and locked for older kids. Safe storage was reported in:

➤ 32.5% of households with only young children

➤ 11.7% of households with only older children

➤ 29.0% of households with children in both age groups

McDonald, E. M., et. al. (2017). Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children. Pediatrics, 139(3). doi:10.1542/peds.2016‐2161

Image source: https://www.checkupnewsroom.com/accidental‐overdose‐of‐a‐child‐‐‐mistaking‐pills‐for‐candy/

PEDIATRIC POISONING➤ Perceived barriers to storing opioids in a locked place:

➤ More trouble than it’s worth, takes too much time

➤ Too hard for me to use my medication➤ Most parents believe that storing opioids in a locked place is a good way

to keep their child safe, whether or not they do it themselves. ➤ Most parents reported lower perception of threats and benefits with

older children than with younger children.

McDonald, E. M., et. al. (2017). Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children. Pediatrics, 139(3). doi:10.1542/peds.2016‐2161

Image source: http://www.onlineparentingcoach.com/2012/03/teens‐who‐steal‐prescription‐drugs‐from.html

PEDIATRIC POISONING

➤ In a study in 2011, the most common cause of poisoning‐related deaths in children younger than 5 years was analgesics (21.1%).

➤ A single adult dose of an opioid can be enough to kill a child.➤ Risk factors associated with pediatric poisonings:

➤ First in birth order➤ Mother with perinatal depression➤ A single adult in the household➤ Maternal alcohol misuse

➤ Safety recommendations: ➤ Never store cleaners/medications in bottles or containers that were

previously used for food. ➤ Don’t call medicine “candy” to get a child to take it.

Canares, T. L. (2015). Poisoning Prevention. Pediatrics in Review, 36(2), 82‐85. doi:10.1542/pir.36‐2‐82

PEDIATRIC POISONING

➤ Children of mothers prescribed opioids are at substantially greater risk of opioid toxicity.

➤ In this study of children age 10 and under, 50% of cases of opioid toxicity were in children <2yrs.

➤ The concurrent maternal use of antidepressants further increased risk of pediatric opioid overdose.

➤ Limitations: this study only includes prescription opioids, not the presence of illicit opioids in the household.

Finkelstein, Y., Macdonald, E. M., Gonzalez, A., Sivilotti, M. L., Mamdani, M. M., & Juurlink, D. N. (2017). Overdose Risk in Young Children of Women Prescribed Opioids. Pediatrics, 139(3). doi:10.1542/peds.2016-2887

PEDIATRIC POISONING AND NON‐MEDICAL USE OF OPIOIDS

➤ Review of a Poison Control database.➤ Due to concern in the early 1990s that physicians were not adequately

treating pain, opioid prescriptions quadrupled from 1999 ‐ 2010. ➤ 80% of opioid prescriptions worldwide are made in the US. ➤ Annual number of opioid exposures increased by 86.0% from 2000‐2009,

then decreased by 31.4% from 2011‐2015. ➤ Buprenorphine exposures declined in 2011‐2013 then increased in 2014‐2015. ➤ Rate of suspected suicide by teenagers increased by 52.7% from 2000‐2015.

Allen, J. D., et. al. (2017). Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000–2015. Pediatrics, 139(4). doi:10.1542/peds.2016‐3382

Image source: https://www.cnn.com/2017/09/18/health/opioid‐crisis‐fast‐facts/index.html

PEDIATRIC POISONING AND NON‐MEDICAL USE OF OPIOIDS

➤ Children ages 0‐5 had the largest number of exposures. ➤ Teenagers had greater odds of serious medical outcomes. ➤ Serious clinical side effects (total patients included: n=188,468):

➤ Respiratory depression (1.8%; n=3,386)➤ Coma (0.8%; n=1479)➤ Hypotension (0.4%; n=757)➤ Respiratory arrest (0.2%; n=463)➤ Cardiac arrest/asystole (n=0.1%; n=195)

Allen, J. D., et. al. (2017). Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000–2015. Pediatrics, 139(4). doi:10.1542/peds.2016‐3382

NON‐MEDICAL USE OF OPIOIDS

➤ Review of data from the Monitoring the Future surveys given to 12th graders between 1975 and 2015.

➤ Findings: ➤ Medical use of opioids was the most prevalent opioid exposure.➤ The majority of adolescents who reported nonmedical opioid use had

previously used opioids medically.➤ Male nonmedical opioid users are more like to use opioids prescription

opioids to get high, while female are more likely to use them for physical pain relief.

➤ The decline in medical and nonmedical use of opioids from 2013‐2015 coincides with declines in opioid prescriptions during that time.

Mccabe, S. E., West, B. T., Veliz, P., Mccabe, V. V., Stoddard, S. A., & Boyd, C. J. (2017). Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 1976–2015. Pediatrics, 139(4). doi:10.1542/peds.2016‐2387


➤ Recommendations: ➤ Routine use of prescription drug monitoring programs to help identify

misuse.➤ Discussion with adolescents and parents about risks of benefits of pain

management with and without prescription opioids including proper storage, monitoring, and disposal of medications.

➤ Routine screening for nonmedical opioid use and other substance use disorders

➤ Providing lowest effective dosages and minimum quantity with concomitant use of acetaminophen or ibuprofen to decrease opioid requirement.

Mccabe, S. E., West, B. T., Veliz, P., Mccabe, V. V., Stoddard, S. A., & Boyd, C. J. (2017). Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 197


➤ About 467,000 adolescents ages 12‐17 years engage in non‐medical use of prescription pain relievers, and 168,000 are addicted (2014 National Survey on Drug Use and Health).

➤ 28,000 had heroin in the past year, 18,000 have a heroin use disorder.

➤ Starting at a younger age can be linked to increased severity of addiction.

➤ Most youths who start using opioids illicitly take prescription drugs that were prescribed for an adult.

Kemp, C. (2016). AAP Conference Preview: Protect your patients from opioid addiction. AAP News.Image source: https://www.livescience.com/44036-heroin.html


➤ Baseline risk stratification of adolescents into three groups based on drug use behaviors, attitudes, grades, education level of parents, and ethnicity using data from the Monitoring the Future study.

➤ Those who were prescribed opioids as adolescents had a 33% higher risk of misusing them by age 23 compared to those who were never prescribed opioids.

➤ The most common reasons respondents gave for misuse were "to feel good or get high" and "to relax or relieve tension”.

Miech, R., Johnston, L., Omalley, P. M., Keyes, K. M., & Heard, K. (2015). Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics, 136(5). doi:10.1542/peds.2015-1364Jenco, M. (2015). Study: Prescription opioid use in teens associated with future misuse. AAP News.


➤ Those who had negative attitudes about drugs and little experience using them (low risk groups on baseline stratification) were significantly more likely to misuse opioids in the future.➤ Researchers theorized that adolescents who initially perceived as low‐risk

may have gone on to misuse opioids due to the novelty. After having used them legitimately, they may have perceived them as safe and pleasurable.

➤ While this group was more likely to misuse opioids in the future, they did have low frequency of use (<5 uses in the past year).

Miech, R., Johnston, L., Omalley, P. M., Keyes, K. M., & Heard, K. (2015). Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics, 136(5). doi:10.1542/peds.2015-1364Jenco, M. (2015). Study: Prescription opioid use in teens associated with future misuse. AAP News.

POST‐OP/PRESCRIPTION

➤ Surgical care is one of the most common medical encounters associated with opioid prescription and is an important risk factor for prolonged prescription opioid use in adolescents.

➤ Retrospective cohort study of opioid naive adolescents and young adults comparing prolonged opioid use in post‐operative patients with prolonged use in a non‐surgical cohort.

➤ Prolonged opioid use was defined as a refill 90‐180 days after surgery.

Harbaugh CM, Lee JS, Hu HM, et al. Persistent Opioid Use Among Pediatric Patients After Surgery. Pediatrics. 2018;141(1):e20172439

Image source: https://www psychiatryadvisor com/childadolescent psychiatry/adolescents psychiatric disorders rates of opioid use/article/752063/


➤ Prolonged opioid use found in 4.8% (range of 2.7% to 15.2% across procedures) in the surgical group compared to 0.1 in the nonsurgical comparison group.

➤ Secondary findings that patients with prolonged opioid use filled additional opioid prescriptions not only of extended duration but also of substantial quantity (200‐300 oral morphine equivalents).

➤ No association with more painful procedures and prolonged opioid use.

➤ Surgeries most associated with prolonged opioid use: cholecystectomy, colectomy.



➤ Context: Boxed warning issued by FDA in 2012 advising that codeine use after tonsillectomy may lead to life‐threatening respiratory failure.

➤ Randomized clinical trial in children post‐op days 1‐5 after tonsillectomy +/‐ adenoidectomy. One group was given acetaminophen + morphine, the other group was given acetaminophen + ibuprofen.

➤ Primary outcome: respiratory events/desaturations during sleep ‐increased in morphine group

➤ No difference in post‐op bleeding in NSAIDs group.➤ No difference in post‐op pain.

Kelly, L. E., et. al. (2015). Morphine or Ibuprofen for Post-Tonsillectomy Analgesia: A Randomized Trial. Pediatrics, 135(2), 307-313. doi:10.1542/peds.2014-1906

NEONATAL OPIOID EXPOSURE

➤ Neonatal complications associated with antenatal opioid exposure ➤ Low birth weight➤ Preterm delivery➤ Respiratory symptoms➤ Feeding difficulty➤ Seizures

➤ Predictors of increased risk of neonatal abstinence syndrome➤ Antenatal cumulative prescription opioid exposure➤ Opioid type (maintenance or long‐acting opioids > short‐acting)➤ Tobacco use➤ SSRI use➤ Musculoskeletal disease➤ Headache or migraine

Patrick, S. W., et. al. (2015). Prescription Opioid Epidemic and Infant Outcomes. Pediatrics, 135(5). doi:10.1542/peds.2014-3299dImage source: https://www.babycentre.co.uk/a25005123/first-24-hours-newborn-crying


➤ Women prescribed opioids were more likely to have depression, anxiety, and tobacco use.

➤ 65% of infants with neonatal abstinence syndrome (NAS) were exposed to legally obtained opioids

➤ Limitations: high rates of polysubstance exposure in infants with NAS makes it difficult to study the effects of opioids alone in this retrospective study

Patrick, S. W., et. al. (2015). Prescription Opioid Epidemic and Infant Outcomes. Pediatrics, 135(5). doi:10.1542/peds.2014-3299d


➤ An estimated 400,000 US infants are exposed to drugs or alcohol in utero each year.

➤ Unintended pregnancy in women with opioid use disorder is as high as 85% (compared to 31‐47% in the overall population.

➤ Discontinuation of opioids or medically‐supervised withdrawal is not recommended during pregnancy ‐ standard of care is with opioid agonist therapy (methadone, buprenorphine)

➤ Punitive measures taken against pregnant women with substance abuse disorder (criminalization, prosecution) may lead to avoidance of prenatal care and avoidance of drug testing and treatment.

Patrick SW, Schiff DM, AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. A Public Health Response to Opioid Use in Pregnancy. PediaKemp, C. (2017). Policy calls for public health approach to opioid misuse by pregnant women. AAP News.


➤ Recommendations: ➤ Primary prevention ‐ educating the public about addictive prescription

opioids and expanding access to reproductive health services.➤ Screening of all women for substance use early, and several times during

prenatal care➤ Consent for drug screening and informing women how positive results will

be used for treatment and reporting requirements. ➤ Criminal justice approaches ‐ healthcare providers should be aware of

state reporting requirements. ➤ Increasing child welfare and social support systems to provide optimal care to families.

Patrick SW, Schiff DM, AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. A Public Health Response to Opioid Use in Pregnancy. Pediatrics. 2017;139(3):e20Kemp, C. (2017). Policy calls for public health approach to opioid misuse by pregnant women. AAP News.Image source: https://www.independent.co.uk/life-style/baby-brain-pregnancy-real-memory-loss-task-performance-worse-women-research-a8161921.html

SPORTS AND OPIOIDS

➤ Teen athletes are less likely to abuse prescription opioids and heroin than non‐athletes.

➤ The physical activity and positive social connections embedded within sport may serve as a positive developmental experience that can potentially deter youth from serious types of illicit substance use like NPOU (nonmedical prescription opioid use), heroin or cocaine.

➤ While athletes in high injury sports should be monitored for opioid analgesic prescriptions and misuse, the overwhelming majority of athletes do not participate in these types of sports and are not at a higher risk of using or misusing prescription opioids or heroin.

First, L. (2016). The US Opioid Epidemic and Adolescent Sports - A Negative Association Worth Knowing About. American Academy of Pediatrics.Jenco, M. (2016). Study: Sports participation may keep teens from using heroin. AAP News.

Veliz P, Boyd CJ, McCabe SE. Nonmedical Pre‐ scription Opioid and Heroin Use Among Adolescents Who Engage in Sports and Exercise. Pediatrics. 2016;138(2):

ADDICTION/TREATMENT

➤ Treatment options for Opioid Use Disorder: ➤ Methadone: full opioid agonist; only available in methadone clinics; strict

guidelines restrict when minors can qualify. ➤ Naltrexone: opioid antagonist; can precipitate sudden withdrawal if opioids

used recently➤ Buprenorphine +/‐ naloxone: partial agonist; buprenorphine can be used in

pregnant females➤ Treatment Protocol:

➤ Clinical model should include a pediatrician and a mental health practitioner to provide behavioral therapy.

➤ Initial visit: Assessment for opioid use disorder using DSM‐V criteria, education, treatment agreement, lab testing, vaccinations, discussions about safe storage of medications.

➤ Follow up visits: urine drug testing, behavioral health support, continued education

Carney, B. L., Hadland, S. E., & Bagley, S. M. (2018). Medication Treatment of Adolescent Opioid Use Disorder in Primary Care. Pediatrics in Review, 39(1), 43-45. doi:10.1542/pir.2017-0153

ADDICTION/TREATMENT

➤ Despite the established efficacy of medication treatment and potentially devastating consequences of untreated opioid addiction, utilization of medications for opioid use disorders remains low, particularly in youths. ➤ Potential barriers: Current policies, stigma and attitudes

➤ Methadone can only be prescribed by specialized treatment programs, few of which are able to accept patients younger than 18.

➤ Physicians must complete training and apply for a waiver in order to prescribe buprenorphine.

AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Pediatrics.

2016;138(3):e20161893 Levy, S. (2016). Effective treatments for opioid use disorder underused in youths: AAP. AAP News. Image source: https://www.thefix.com/content/take-home-methadone-doses-sold-streets91255

ADDICTION/TREATMENT

➤ Recommendations: ➤ Advocate for increasing resources to improve access to medication‐

assisted treatment of adolescents and young adults addicted to opioids.

➤ Consider offering medication‐assisted treatment to adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service.

➤ Support further research focusing on developmentally appropriate treatment of substance use disorders in adolescents and young adults, including primary and secondary prevention, behavioral interventions and medication treatment.

AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Pediatrics.

2016;138(3):e20161893 Levy, S. (2016). Effective treatments for opioid use disorder underused in youths: AAP. AAP News.

TREATMENT

➤ Opioid bundle components: ➤ Prescription drug monitoring

report➤ Urine drug screen➤ Questionnaire to screen for

personal or family history of drug abuse or mental health disorders

➤ Pill count

➤ Quality improvement project of the Pediatric Palliative and Comfort Care Team at Cincinnati Children’s Hospital to develop an “opioid bundle” to risk stratify all patients for opioid misuse and improve safe opioid prescribing practices.

Thienprayoon R, Porter K, Tate M, et al. Risk Stratification for Opioid Misuse in Children, Adolescents, and Young Adults: A Quality Improvement Project. Pediatrics. 2017

SAFE PRESCRIBING PRACTICES AND PROPOSED SOLUTIONS➤ Study evaluated data from emergency room and urgent care

discharges ‐ patient age, sex, ethnicity, diagnosis, prescriber, type of medication, duration, and number of refills.

➤ Goal: improving prescribing practices to decrease the amount of opioids available for nonmedical use.

➤ Patients more likely to receive opioid prescription for >5 days: ➤ Age < 9yrs➤ Diagnosis was not an injury➤ Prescribed by a resident

➤ Mean duration 4.4 days (range 1‐44 days, 20% for >5 days)➤ No prescriptions included refills

Dephillips, M., Watts, J., Lowry, J., & Dowd, M. D. (2017). Opioid Prescribing Practices in Pediatric Acute Care Settings. Pediatric Emergency Care, 1. doi:10.1097/pec.0000000000001239Kemp, C. (2017). Opioids more likely to be prescribed to younger patients, by residents. AAP News.

SAFE PRESCRIBING PRACTICES AND PROPOSED SOLUTIONS

➤ “Every time we prescribe opioid drugs there is a risk for potential abuse.”

➤ The 2016 Monitoring the Future survey showed a 45% drop in the nonmedical use of prescription opioid pain relievers among 12th‐graders compared to five years ago.

➤ What can Pediatricians do?➤ Limit opioid prescriptions to seven days or less➤ Make use of chronic pain clinics for patients➤ Limit duration of opioid use in post‐op patients, and use opioids in

combination with NSAIDS and oral anticonvulsants.

Kemp, C. (2017). Kemp, C. (2017). Opioids more likely to be prescribed to younger patients, by residents. AAP News. AAP News.

EDUCATION CODE➤ EDUCATION CODE ‐ EDC➤ TITLE 2. ELEMENTARY AND SECONDARY EDUCATION [33000 ‐ 64100]➤ ( Title 2 enacted by Stats. 1976, Ch. 1010. )➤ DIVISION 4. INSTRUCTION AND SERVICES [46000 ‐ 65001]➤ ( Division 4 enacted by Stats. 1976, Ch. 1010. )➤ PART 27. PUPILS [48000 ‐ 49703]➤ ( Part 27 enacted by Stats. 1976, Ch. 1010. )➤ CHAPTER 9. Pupil and Personnel Health [49400 ‐ 49590]➤ ( Chapter 9 enacted by Stats. 1976, Ch. 1010. )➤

ARTICLE 1. General Powers—School Boards [49400 ‐ 49417]➤ ( Article 1 enacted by Stats. 1976, Ch. 1010. )

49414.3.

(a) School districts, county offices of education, and charter schools may provide emergency naloxonehydrochloride or another opioid antagonist to school nurses or trained personnel who have volunteered pursuant to subdivision (d), and school nurses or trained personnel may use naloxonehydrochloride or another opioid antagonist to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an opioid overdose.

VIDEO OF HOW TO USE

➤ https://www.narcan.com/patients/how‐to‐use‐narcan/

NASAL SPRAY NALOXONE

***TAKE‐BACK SITES AND WEBSITE***

➤ https://takebackday.dea.gov/

SOURCESAAP Committee on Substance Use and Prevention. Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Pediatrics.

2016;138(3):e20161893

Allen, J. D., et. al. (2017). Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000–2015. Pediatrics,139(4). doi:10.1542/peds.2016-3382

Canares, T. L. (2015). Poisoning Prevention. Pediatrics in Review, 36(2), 82-85. doi:10.1542/pir.36-2-82

Carney, B. L., Hadland, S. E., & Bagley, S. M. (2018). Medication Treatment of Adolescent Opioid Use Disorder in Primary Care. Pediatrics in Review, 39(1), 43-45. doi:10.1542/pir.2017-0153

Dephillips, M., Watts, J., Lowry, J., & Dowd, M. D. (2017). Opioid Prescribing Practices in Pediatric Acute Care Settings. Pediatric Emergency Care, 1. doi:10.1097/pec.0000000000001239

Finkelstein, Y., Macdonald, E. M., Gonzalez, A., Sivilotti, M. L., Mamdani, M. M., & Juurlink, D. N. (2017). Overdose Risk in Young Children of Women Prescribed Opioids. Pediatrics, 139(3). doi:10.1542/peds.2016-2887

First, L. (2016). The US Opioid Epidemic and Adolescent Sports - A Negative Association Worth Knowing About. American Academy of Pediatrics.


Jenco, M. (2015). Study: Prescription opioid use in teens associated with future misuse. AAP News.

Jenco, M. (2016). Study: Sports participation may keep teens from using heroin. AAP News.

Kelly, L. E., et. al. (2015). Morphine or Ibuprofen for Post-Tonsillectomy Analgesia: A Randomized Trial. Pediatrics, 135(2), 307-313. doi:10.1542/peds.2014-1906

Kemp, C. (2017). Opioids more likely to be prescribed to younger patients, by residents. AAP News.

Kemp, C. (2016). AAP Conference Preview: Protect your patients from opioid addiction. AAP News.

SOURCESKemp, C. (2017). Policy calls for public health approach to opioid misuse by pregnant women. AAP News.

Kemp, C. (2017). Kemp, C. (2017). Opioids more likely to be prescribed to younger patients, by residents. AAP News. AAP News.

Levy, S. (2016). Effective treatments for opioid use disorder underused in youths: AAP. AAP News.

Mccabe, S. E., West, B. T., Veliz, P., Mccabe, V. V., Stoddard, S. A., & Boyd, C. J. (2017). Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 1976–2015. Pediatrics, 139(4). doi:10.1542/peds.2016-2387

McDonald, E. M., et. al. (2017). Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children. Pediatrics, 139(3). doi:10.1542/peds.2016-2161

Miech, R., Johnston, L., Omalley, P. M., Keyes, K. M., & Heard, K. (2015). Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics, 136(5). doi:10.1542/peds.2015-1364

Patrick, S. W., et. al. (2015). Prescription Opioid Epidemic and Infant Outcomes. Pediatrics, 135(5). doi:10.1542/peds.2014-3299d

Patrick SW, Schiff DM, AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. A Public Health Response to Opioid Use in

Pregnancy. Pediatrics. 2017;139(3):e20164070

Thienprayoon R, Porter K, Tate M, et al. Risk Stratification for Opioid Misuse in Children, Adolescents, and Young Adults: A Quality

Improvement Project. Pediatrics. 2017;139(1): e20160258

Veliz P, Boyd CJ, McCabe SE. Nonmedical Pre- scription Opioid and Heroin Use Among Adolescents Who Engage in Sports and Exercise. Pediatrics. 2016;138(2): e20160677

pediatric opioid use and misuse · pediatric poisoning in a study in 2011, the most common cause of...

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