Opioids: A pediatric epidemic
Pediatricians may not recognize the growing problem of opioid abuse in their communities. As a result, physicians need to carefully examine their prescribing practices.
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.
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.