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An Escalating Public Health Crisis in Pediatrics

Op-Med is a collection of original articles contributed by Doximity members.
Doximity coverage of the opioid crisis at AAP 2017

  • Rise in teens becoming addicted to opioid painkillers after common surgeries
  • Adverse reactions to opioids in children have doubled since 2013
  • Emergency Rooms treating 135 children addicted to opioids every day on average

Opioid misuse and addiction in children and young people is a rapidly evolving ‘public health crisis’, according to several studies presented at this week’s American Academy of Pediatrics (AAP) National Conference & Exhibition in Chicago, IL.

Over 2 million Americans are estimated to be dependent on opioids (including prescription painkillers and heroin), which killed more than 33,000 people in 2015, according to the Center for Disease Control and Prevention. Now data released at the AAP 2017 National Conference suggests that the opioid epidemic among children and adolescents is worsening. This is driven partly by the substantial rise in the use of opioid painkillers in hospitals, but an alarming number of young people already have an addiction. Worryingly, researchers warn that this may just be the tip of the iceberg.

Common surgeries may be leading to prescription opioid abuse in adolescents

Researchers from the Michigan Opioid Prescribing Engagement Network examined data from almost 90,000 privately insured young Americans (aged 13 to 21 years), without any history of opioid addiction, to identify how many adolescents were using opioid painkillers between three and six months after common surgeries.

The results showed that around 5% of adolescents fill an additional opioid prescription three to six months after surgery compared to just 0.1% of age-matched controls.

“This is the first study to show that long-term opioid use may be a significant problem for adolescents and young adults who have surgery”, said co-author Calista Harbaugh, a general surgery resident at the University of Michigan Medical School, MI.

The highest risk factors were patient characteristics, that particularly included older age with chronic conditions, depression, anxiety, and prior substance abuse.

“There are no specific guidelines on how much opioid to give kids after surgery,” Dr Harbaugh told Doximity. Studies show that there is wide variation in the amount of opioids prescribed. “So we need to have evidence-based best practices for providers to help them understand how much to give, and so that patients know what to do with their medication at home,” she added.

Adverse reactions to opioid painkillers on the rise

A second study looked at hospital records of children (aged one month to 17 years) from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project Kids’ Inpatient Database between 2003 and 2012.

“We found opioid-related problems were relatively common in hospitalized children,” said co-author Jessica Barreto, a pediatric resident at Nicklaus Children’s Hospital in Miami. Over the nine years, for every 10,000 discharges, 16.6 children experienced adverse reactions to opioid painkillers. And it’s on the rise. In 2003, it was 13.3 per 10,000, and by 2012, it had risen to 20.8.

Adverse effects included opioid withdrawal, which affected 3.1 % of the hospitalized children, constipation (12.5%), altered mental status (10.5%), urinary retention (2.3%), cardiac arrest (1%), and anaphylaxis (0.75%).

“For the past two decades, doctors have been increasingly recognizing and treating pain in children. Unfortunately, the efforts to improve pain management in children have led to a significant rise in the use of opioids both within hospitals as well as in the outpatient setting,” said Dr Barreto.

Just the tip of the iceberg

Another study looked at data from the Nationwide Emergency Department Sample between 2008 and 2013 to gauge the number of children who test positive for opioid abuse.

Analysis revealed that the number of patients 21 and younger that tested positive for opioids rose from 32,235 in 2008 to 49,626 in 2013. “In 2008, about 88 kids tested positive in the emergency department every day for opioid abuse or dependence. It was very concerning to see that by the last year of our study, an average of 135 children each day were testing positive,” said Veerajalandhar Allareddy, one of the authors and Medical Director of the Pediatric Intensive Care Unit at the University of Iowa Stead Family Children’s Hospital, Iowa City, IA. “That’s a big jump. In our opinion, this is a pediatric public health crisis,” he added.

What the study does not define is whether these are prescription or non-prescription related cases. What’s more, it only looked at young people who visited the emergency department. Young people can go to their primary care doctor, an urgent care facility, or be admitted directly into the hospital. “So it is probably just the tip of the iceberg”, Dr Allareddy emphasized. “At every level we need to screen these kids at least with some basic questions, and then, if there is a concern, to test them biologically”, he added.

Alternative methods of pain management

All the studies call for more research to find less-toxic, non-addictive strategies to manage chronic pain in children. The next step is to look at who is prescribing opioids (who we can target), the amount patients really need, and whether they actually need an opioid or are there are alternative pain management methods that should be used. Importantly, Dr Harbaugh asserted that, “We need to have proper communication around this issue so that we can help kids that are non-medically using opioids or are addicted.”

Presented at American Academy of Pediatrics (AAP) National Conference & Exhibition in Chicago, IL.

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