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Opioid use is now a significant problem for the pediatrician and the families served in pediatric practices. Whereas patients with a prior history of drug use, misuse, or suspicions of drug misuse have long been studied, monitored, screened, and treated for adverse outcomes, opioid-naïve patients with legitimate medical reasons for opioid prescriptions may represent a greater risk for opioid complications.
Opioid use is now a significant problem for the pediatrician and the families served in pediatric practices. Whereas patients with a prior history of drug use, misuse, or suspicions of drug misuse have long been studied, monitored, screened, and treated for adverse outcomes, opioid-naÃ¯ve patients with legitimate medical reasons for opioid prescriptions may represent a greater risk for opioid complications.
Although marijuana and alcohol abuse are declining, abuse of prescription opioids has more than doubled.1 Prescription opioids were second only to marijuana for 2.2 million adolescent first-time users of an illicit drug in 2009.2
Pediatric providers, in fact, may be dispensing more opioids than are needed and contributing to the nonmedical use of opioids.3,4
One of the major concerns is that compared with other drugs of abuse among adolescents, the temporal progression from initiation to addiction among opioids is both common and accelerated.5 This article will review a number of concepts and problems as well as provide some practical pointers for dealing with this problem in a busy office practice.
Description of the problem
Failing grades, changes in friends, changes in appearance, discipline problems, legal problems, social problems, or overdose represent the myriad of ways that an opioid use disorder may present to the pediatric practice. Frighteningly for both parents and the pediatrician, opioid use disorder can present as a fatal event in the absence of dependence, family knowledge of a problem, or even with first use.5 Although many pediatricians might not think this issue impacts their practice, the following statistics point out that there are probably very few pediatric practices not impacted by this growing epidemic:
· Unaware of the risks of nonmedical opioid use, most adolescents misusing opioids receive them free from a friend or relative.6
· Opioid prescriptions to adolescents and young adults nearly doubled from 1994 to 2007.7
· In 2014, there were more than 460,000 adolescents who were current nonmedical users of pain relievers, and 168,000 had an addiction to prescription pain relievers.8
· In 2014, 28,000 adolescents used heroin in the prior year and 16,000 were current users.8
· In 2013, 169,000 adolescents and young adults used heroin for the first time.9
· In 2009, 1.2% of high school students self-reported heroin use at least once.2
· In 2011, nearly 9% of high school seniors illegally used nonmedical prescription opioids in the last year,10 with a 13% incidence of lifetime use.11
· The socioeconomic status of pediatric patients beginning nonmedical use of opioids is increasing.5
· Drug overdose death rates have increased more than 250% since 2001, with much of the increase attributed to opioids.5
· In New York City, unintentional opioid overdose deaths increased from 59 to 220 between 2000 and 2011.12
· More boys seek treatment for heroin abuse compared with girls, but girls are more likely to be injection users.5
· Forty percent to 90% of adolescent opioid abusers will transition to heroin use.5
Whereas more recent reports find a decline in the nonmedical use of opioids among pediatric patients, heroin is also being used at a much younger age.
Where do kids get opioids?
Opioids are relatively easy to get given the extent to which they are prescribed in the United States today. Adolescents often need to go no further than a nearby handbag, kitchen counter, or medicine cabinet-a drug dealer is not required.5
Adult prescription of opioids increasingly are noted to be related to adolescent exposures resulting in emergency department visits, hospitalization, and death. Following the Joint Commission emphasis on pain control and subsequent increase of opioid prescriptions of more than 300% beginning in 2000, both the number and severity of adolescent opioid-related events reported to poison control centers increased significantly.13 Among adolescents, this is more likely to represent intentional use (eg, recreational or intent for self-harm) compared with younger pediatric patients for whom accidental ingestion is more likely.14
Opioids are also increasingly prescribed to adolescents, potentially excessively. In a large study of pain medication scripts issued after a tooth extraction, a 3-fold difference was noted in the morphine equivalents between the 10th and 90th percentiles for a given procedure. This would suggest that at least some patients are being prescribed opioids excessively. Of particular concern in this study, patients aged between 14 and 17 years and 18 to 24 years had the highest percentage of filled prescriptions.15 Other studies have demonstrated increased risk of recurrent and increasing dosages, opioid use among patients believed to have relatively minor medical problems, and prescribed opioids legitimately.15-17
Do kids understand the risks?
Despite wide media and medical reporting of the increasing problems of prescription opioids, adolescents may not be aware of or understand the risks. Much of the literature describing high-risk populations specifically targets the young adult (eg, those aged 18 to 25 years) so the adolescent population could be thought of as even less knowledgeable and less prepared.
Because opioids are prescribed by physicians, these drugs are legal and regulated by governments. Nonmedical use of prescription opioids often is not recognized as potentially harmful and may even be viewed as harmless, especially compared with drugs such as heroin. In general, these prescription drugs are also viewed as socially acceptable. This is further supported by popular beliefs that associate heroin as a “dangerous street drug” and prescription opioids not being associated with such a negative cultural narrative.12
Adolescents may also have the misbelief that prescription opioids are safer than heroin, and that noninjection routes of administration are associated with less risk of overdose compared with injection routes.12 As a result of these misbeliefs, adolescents may be more likely to overdose from prescription opioids because they underestimate the potency of the drug they are using and they see their use as very different from that from what they consider to be street users.
Additionally, knowledge regarding factors that increase risk of overdose, preventing overdose, and addressing an overdose when it occurs are limited. Further, there is a great deal of misinformation and lack of understanding related to overdose risk and polysubstance use among nonmedical users of opioids. Similarly, few nonmedical users of opioids are familiar with naloxone or its appropriate use for treating opioid overdose.12
Other beliefs impact young adults’ decisions and actions related to opioids. Many young adults see very clear differences between nonmedical users of prescription opioids and persons they view as “junkies.” There is a perception among this group that heroin users are low income and more severely addicted despite opioid addiction being highest among white males and increasingly being associated with higher socioeconomic status.5,12 In fact, prevalence of drug misuse is actually low among minority adolescents and a great deal of current research is focusing on identifying protective factors.18-20 Interestingly, these beliefs persist among nonmedical users of prescription opioids who transition to heroin use.12
Which kids are at risk?
Estimates of the genetic component of addiction risk range from 40% to 60%, and the thought is that the risk applies equally across all substances.5 Although there is some discussion of genetic testing to guide treatment in chronic pain treatment among adults,21 this author could find no recommendation for genetic testing to determine risk among adolescent patients.
Environmental risk factors can increase risk generally or specifically for opioids. Stress and exposure to drug use among family or friends are thought to generally increase addiction risk. Depression, anxiety, and other comorbid psychiatric disorders also increase risk. Developmental vulnerabilities such as excitement seeking, extreme extroversion, and impulsivity generally increase the risk for adolescents to addiction.5 Access to opioids, through either appropriate medical use or nonmedical use, as well as permissive attitudes toward opioids are more specific risk factors for opioid addiction.Cheaper prices of heroin might also predict increased use among adolescents who are more price sensitive in their use behaviors.
A University of Michigan online survey identified 13.9% misuse of opioids among nearly 3000 adolescents.10 Among misuse, a medical reason was most common and was associated with increased pain, anxiety, depression, and a history of sexual victimization. The other large grouping for misuse was nonmedical abuse that included predilection toward rule-breaking behavior, aggressive behavior, risk for substance dependence, and use of illicit drugs.
Of particular concern are findings of the potential for abuse even among appropriate uses of opioids because many current providers were taught that the risk of misuse among patients with appropriate indications was particularly low. Among a nationally representative sample of high school seniors, legitimate indication for and opioid use before graduation from high school increased risk of nonmedical use of a prescription opioid between the ages of 19 and 23 years by 33%.20 These patients had little or no history of drug use and appropriately negative views of illegal drug use at baseline. Further findings similar to these could certainly change the risk benefit equation for many pediatricians in regard to prescription of opioids.
Similarly, most providers would think that aberrant opioid-associated behaviors would be minimal in a population for which opioids are clearly indicated, such as cancer treatment. However, a study of an academic pediatric oncology practice identified a 11.7% rate of misuse.22 Examples of inappropriate behaviors included requesting specific drugs by brand names, resisting regimen changes, excessive phone calls to obtain more medication without a visit, and seeking pain treatment from multiple providers. Risk factors for substance abuse included history of prior addiction, anxiety, depression, attention-deficit/hyperactivity disorder, or some other mental health disorder.
In drug-naÃ¯ve patients, the opioid prescription may represent their first interaction with an addictive drug. The initial experience is likely pleasurable and safe-a key factor in many theories of drug abuse. On the other hand, a legitimate prescription for an opioid is less likely to make a large impact on a patient with more exposure to other drugs.20 When one considers these factors in the face of the previous discussion about where children are getting opioids, the pediatrician may have great concern about general prescribing practices of opioids.
Opioids as a gateway
Alcohol, cigarettes, and marijuana are individually associated with current abuse of prescription opioids among 18- to 25-year-old men, but only marijuana use was similarly associated with young women in one study pooling data from the 2006, 2007, and 2008 National Survey on Drug Use and Health.23 Prescription opioid use also may be a gateway to heroin use despite a 10-fold greater prevalence of prescription opioid use.5 This is hypothesized to be attributed to rising costs for prescription opioids, a declining cost of heroin, and the increased potency of heroin providing a cheaper/better alternative, especially once addiction is established.
How to screen for opioid problems
Given the width and breadth of the opioid problem, multiple approaches are required. Because of the greater impact of opioids on younger patients, it is essential to limit the access of prescription opioids by children and adolescents who would abuse them while still providing adequate pain management to those who need it.
Substance abuse screening tools such as the CAGE-AID24 and CRAFFT25 are validated tools that can be used to briefly assess adolescents for substance use disorders. The tools can be used in the busy pediatric practice to identify if a more in-depth conversation about drug use is appropriate.
The pediatrician must restrict opioid prescriptions to patients who truly need them. The pediatrician and clinical staff need to be educated about the risks of opioid misuse and also how to appropriately counsel parents about opioid risks. Furthermore, pediatricians need to discuss not only the risk of accidental ingestion because of the presence of opioids in a home, but also the risks related to nonmedical use of opioids among adolescents.
The future risk of the opioid-naÃ¯ve patient should be considered in both prescribing decisions and patient counseling efforts given the emerging literature on the risk of short-term prescriptions with current and future misuse.15-17,20 Because of these risks, the pediatrician should consider discussing and offering nonopioid therapy for the treatment of minor painful conditions. One strategy might be to employ nonopioid therapy first line and reserve opioids for patients in whom these treatments are insufficient.20 Likewise, both parents and the pediatrician need to monitor for signs of misuse among patients for whom opioid treatments are appropriate.
Opioids are likely a growing problem for the pediatric practice whether or not the pediatrician recognizes the problem in his or her community. The misconception that opioid problems are centered among lower socioeconomic parts of society may be preventing pediatricians from more fully addressing this problem in their practices. Emerging evidence indicates that very small exposures of opioids can lead to future problems for the pediatric patient. As a result, all pediatricians may need to carefully examine their own prescribing practices.
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