Opioid Abuse in the Pediatric Population: Addressing a Real Public Health Epidemic
ABSTRACT: Misuse and abuse of prescription opioids among children and adolescents is a significant public health problem in the United States. The most common culprits are hydrocodone and oxycodone. It is important that pediatricians distinguish the medical misuse of prescribed opioids from nonmedical abuse. Pain relief is the most common reason for pediatric opioid misuse. Most opioids are obtained through sharing with or borrowing from friends and family. Education, prevention, and regulation are key to reducing opioid misuse and abuse and reducing the associated morbidity and mortality among children and adolescents.
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A 17-year-old high school senior presents for his annual camp physical. After you ask his parents to leave the room so that you can obtain a social history, the adolescent reluctantly tells you that he has been using oxycodone recreationally since having had a dental procedure 2 years ago. He says that he had been prescribed only 10 days’ worth at the time, and that he now gets “oxy” by sharing with or borrowing from other family members and friends. He says he occasionally thinks about quitting and adds that he does not want others to find out about his addiction. He admits that he does not believe he can stop on his own.
This article explores the what, who, why, and how of opioid use, misuse, and abuse in the pediatric population, and it describes the multifactorial methods used to treat and prevent opioid abuse in young patients such as the one in this hypothetical case.
The “What”: Opioids
The use of opiates dates to well over 2,300 years ago. Theophrastus, a successor to Aristotle, is the first person known to have written about opiate use, primarily for the treatment of diarrhea.
The term opiate describes a group of natural plant alkaloid compounds that are produced from the opium poppy plant, Papaver somniferum. Opiates include drugs such as morphine and codeine, as well as semisynthetic derivatives such as hydrocodone, oxycodone and heroin.1 Opioid is a broader term that refers to any molecular compound (natural, semisynthetic, or synthetic) with functional or pharmacologic effects similar to those of an opiate.
Opioids modify nociception. The human nervous system has 4 opioid receptors: μ, κ, δ, and σ. When stimulated, the opioid receptors work via G proteins on presynaptic nerve terminals by decreasing the release of excitatory neurotransmitters in the afferent pathway, thereby dulling the sensation of painful stimuli. Stimulation of the μ-opioidreceptor is what is classically associated with opiate use and causes analgesia, sedation, miosis, decreased gastrointestinal motility, cough suppression, and respiratory depression.
Despite their beneficial effects, opioids have significant and potentially fatal adverse effects if they are misused or abused. The most common adverse effects are nausea, vomiting, constipation, urinary retention, dizziness, and confusion. The pruritus that is frequently associated with opioid use is a side effect of histamine release, as well as a direct central affect that should not be confused with an allergic reaction. At high opioid doses, respiratory depression, coma, and death from respiratory failure can occur.
Prescribed opioids typically are in tablet or capsule form but also are available as solutions, lollipops, or transdermal patches. While pills are designed for oral use, those who abuse them often crush them and sniff or swallow the powder. Crushing the pills, however, might alter the pharmacokinetics, possibly creating a more rapid and stronger effect, particularly with delayed-release formulations. Additionally, coingestion of opioids with other illicit or prescription drugs can have dramatic effects on a user and increase the risk of toxicity. Table 1 lists the street names of commonly abused opioids.2
It is important to clearly understand the distinctions in the terminology used for drug use and drug abuse. Using a medication only in the way the prescriber has instructed and only for the purposes for which it has been prescribed is considered medical use. In contrast, misuse is using a medication in a way that does not adhere to the prescriber’s instructions while still using it for its originally intended effects (eg, using hydrocodone at higher doses or shorter intervals to treat chronic back pain). Nonmedical use or illicit use is using a prescribed medication to obtain a high. The medication might have been obtained legally for a legitimate medical issue or illegally. Abuse is a maladaptive pattern of substance use that results in personal harm to the user. Dependence is similar to abuse but requires some combination of compulsive use of, withdrawal from, and tolerance to a substance (ie, the need for higher doses to obtain the sensation once felt at lower doses).3
How Did This Happen?
The number of prescriptions written for opioids in the United States has ballooned in the last 20 years, and the consequences of this increase now are emerging.4 The number of opioid prescriptions increased threefold from 1999 to 2010.5 In 2009 alone, an estimated 201.9 million prescriptions were written for opioids, of which 11.7% were written for patients from 10 to 29 years of age.6
Among the multifactorial reasons for the increase are the understanding and acceptance of the idea that allowing people with illnesses to suffer in pain is unethical, the demystification of some of the stigmas once associated with opioid use, and the relative ease of purchasing these medications on the Internet.7
The opioid abuse crisis has become a true public health concern that affects the U.S. pediatric population: More than 6% of children from 12 to 17 years of age have engaged in nonmedical opioid use in the past year, according to federal estimates.8 Not surprisingly, children with pathologies that are specifically associated with pain most often are prescribed opioids. In one study, the most common condition in adolescents receiving opioids for non-cancer pain was back pain, followed by headache, neck pain, and arthritis.9
Accompanying this increase in the appropriate medical use of opioids has been a parallel increase in opioid abuse, addiction, and toxicity-related fatalities.4,10 Three major national surveys track illicit drug use: the National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration11; Monitoring the Future (MTF), sponsored by the National Institute on Drug Abuse12; and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).13 While each of these surveys uses different methodologies and outcomes measures, each also includes data on the nonmedical use of prescription opioids (NMUPO).
The NSDUH in 2010 reported that an estimated 2.4 million people over the age of 12 years had initiated use of a prescription opioid for nonmedical purposes.11 MTF reported that hydrocodone in 2011 was the fourth most commonly abused substance by Americans 14 years of age and older, after marijuana, synthetic marijuana, and amphetamine–dextroamphetamine; oxycodone was the 10th most commonly abused.12 Additionally, there were more first-time nonmedical users of prescription opioids in 2006 than there were first-time users of marijuana or cocaine, according to the 2006 NSDUH survey.14
Obtaining prescription opioids for nonmedical use differs from obtaining other illicit drugs (ie, buying illegally from a dealer or a friend). Opioids are most often borrowed or shared.15,16 Many teenagers prefer borrowing medications to seeing a primary care provider for opioid prescriptions. Moreover, 25% of older children report giving away their opioid prescriptions and 10% report trading them.17 Adolescents obtain nearly 34% of opioids for nonmedical use from family members,18 while 17% come from friends.
Who Is at Risk?
In a nationally representative study of more than 7,300 high school seniors from 2007 through 2009, nearly 18% reported the lifetime medical use of prescription opioids, while nearly 13% reported NMUPO.19 Nearly 25% of the teenagers surveyed had exposure to medical or nonmedical prescribed opioids.
A key issue is determining children and adolescents’ motivation for initiating NMUPO. Numerous analyses identify 2 major categories of users: those seeking self-treatment and those using recreationally.15,20-22 The self-medicating group appears to be the larger group, with 79% of high school students15 and 63% of college students20 stating in two different studies that their motivation for NMUPO was pain relief. Further analysis showed that adolescents whose sole intention for NMUPO was to relieve pain had few drug-related problems, were less likely to coingest other drugs, and were less likely to sniff or inject the opioids. In fact, their risk for these behaviors was generally similar to that of students who had never taken prescription opioids.15,20
In a Web-based, self-administered survey of more than 2,500 7th through 12th grade students in Ann Arbor, Michigan, nonmedical abusers were generally characterized as sensation-seeking and rule-breaking with aggressive behaviors, whereas medical or self-treating users were described as having somatic complaints (eg, pain), anxiety, depressive symptoms, or a history of sexual victimization (Table 2).22
Opioid abuse has been shown to be greatly increased in patients with comorbid mental health disorders, with anxiety disorder and depression being the most commonly associated diagnoses.23
The results of these studies show that approaching all nonmedical users of opioids as having a single personality or pathology type is inappropriate. Self-medicating users simply might be seeking treatment for a true emotional or physical pathology, which might be amenable to medications and/or consultation with a mental health professional. The subset of patients categorized as abusers represent a completely different individual type and might be more similar to other illicit drug users than to self-medicators.
Findings of NESARC show that those with a history of appropriate medical use of opioids were more likely to report the later abuse of the medications.13 The most common characteristics of respondents who were prescribed opioids were white ethnicity, relatively lower levels of depressive symptoms, and living at home with both parents.
The age at which persons start using prescription drugs is predictive of their habits later in life. Using data on more than 43,000 participants gleaned from NESARC and the NIAAA’s Alcohol Use Disorder and Associated Disabilities Interview study, one group of authors reported that a higher percentage of participants who had begun using prescription drugs nonmedically at or before the age of 13 years were found to have developed prescription drug abuse and dependence, compared with participants who began using at or after the age of 21 years.24
Over the last 30 years, U.S. drug-related deaths overall have more than doubled, with a quarter of them attributable to alcohol, tobacco, or illicit drug use.25 The death rate from unintentional prescription opioid overdose has quadrupled since 1999.26 In 2008, more than 14,000 unintentional deaths occurred from prescription opioid misuse,27 which is more deaths than from cocaine and heroin combined.26 In a recent survey, 80% of those who started using heroin in the past year had used prescription opioids first.28
Opioid abuse in the adult population can have an adverse effect on children in the following ways:
• Adult opioid use is linked to increased odds for pediatric abuse cases.29
• The presence of opioids in the home increases the risk for accidental pediatric ingestion. Children aged 5 years and younger in the United States had a 100% increase in emergency department visits for accidental ingestions of opioids, with a 92% increase in associated morbidity, from 2001 to 2008.30
• Neonatal abstinence syndrome caused by opioid withdrawal has increased significantly in the last decade, putting newborns with it at risk for numerous medical complications, including seizures.31
Illicit drug use generally is more prevalent in large, urban areas (9.9%) compared with nonmetropolitan areas (6.8%), and it is more common in the Western United States (11.7%) than in other geographic locations (9.6% in the Northeast, 8.6% in the Midwest, and 7.7% in the South).32
Why Do TEENS Abuse Opioids?
In addition to the motivations mentioned above, some authors suggest that adolescents abuse opioid analgesics because of the modeling effect of both family members and peer networks.33,34 Moreover, because these opioids are prescription medications, they are perceived as being socially acceptable and, therefore, perhaps have a less negative association than do “street drugs.”
Boyd and colleagues15 conducted an exploratory study in 2005 in order to determine the motives for prescription medication abuse in a cohort of adolescents between 12 and 18 years of age in Michigan. The top reasons for NMUPO, according to this survey, were to relieve pain, to improve sleep, and to decrease anxiety.
Fewer than 12% of teenagers who abuse opioids receive any treatment at all, according to a study analyzing NSDUH data.35 In fact, only 4.2% of adolescents who met the criteria for dependence actually thought they had a problem and needed help. Of that 4.2% of respondents, 34% said they were not ready to stop, while 22% reported that they did not seek treatment because they did not want others to find out about their problem.35
How to Address the Problem
Multiple approaches are necessary to limit the access of prescription opioids to children and adolescents who would abuse them while simultaneously allowing access to those who need pain management or who need medications to treat opioid dependency.
Education. Physicians must restrict opioid prescriptions to patients who truly need them. All members of the health care team should be educated about the dangers of opioid misuse, and that the presence of opioids in a home increases the risk for purposeful and accidental abuse. Using substance abuse screening tools such as the CAGE-AID36 and CRAFFT37 questionnaires to recognize who is at risk for opioid abuse also is of paramount importance.
Furthermore, physicians should apply a rigid structure to prescribing opioids; for example, they must fully inform parents and young patients about the risks of opioid use and abuse, never write prescriptions for refills, and carefully watch for signs of abuse and openly discuss any concerns.
To avoid opioid misuse or borrowing from friends and family by self-medicators for legitimate conditions, physicians must ask about the status of somatic or psychiatric painful conditions in order to assess whether medication or other therapeutic options are warranted.
Peer usage is a major factor that influences children’s decision to start using drugs.34 However, negative parental attitudes about drugs have been shown to influence children in abstaining. Engaging in a conversation with parents about their role in discussing drugs with their children may be an effective tool in reducing drug use.
Environmental precautions. Because children often obtain prescription opioids from household family members, it is extremely important to avoid the presence of unnecessary medications in the home setting.
Leftover opioids prescribed to family members should be properly disposed of, and those being currently taken should be stored in a safe place. Disposing of narcotics is a complex problem: Physicians cannot legally collect them, discarding them in the trash might allow others easy access to them, and flushing them down the toilet and into the public sewage system could allow them to eventually enter public drinking water. As such, the Office of National Drug Control Policy recommends that these medications be mixed into undesirable, nonedible substances (eg, cat litter, coffee grounds), placed into sealed plastic bags, and placed in the household trash.38
The pharmaceutical industry. The results of one study showed that 80% of opioid abusers in a Kentucky rehabilitation center admitted to tampering with prescription opioid medications’ delivery system (eg, chewing, snorting).39 To reduce the potential for such tampering and abuse, the pharmaceutical industry is utilizing various methods of abuse-deterrent formulations such as physical barriers (crush resistance) or embedded chemicals that render the tampered tablet inert or noxious.40
Regulation. Prescription drug monitoring programs include databases in which the controlled substance prescriptions written by prescribers are recorded and tracked in order to assess for abnormal trends in prescription writing. Clinicians who prescribe opioids much more than average can be contacted and questioned by regulatory officials.
Further legal action can occur at the state level. For example, Florida’s attorney general has launched the “Pill Mill Initiative,” attacking the ability to illegally obtain prescription opioids.41 The campaign aims to remove the state as the “epicenter of prescription drug diversion”—more than 70% of oxycodone pills are prescribed in Florida, and the top prescribers of oxycodone practice in the state.41
Federal regulations have included the passage of the Drug Addiction Treatment Act of 2000, which authorizes only practitioners who meet certain opioid-addiction treatment qualifications to prescribe specific narcotics approved by the Food and Drug Administration (FDA) such as buprenorphine. Moreover, in September 2013, the FDA mandated a change to the safety labeling and marketing of extended-release and long-acting opioids.42
Returning to the case of the 17-year-old with a 2-year history of recreational oxycodone use:
You have a long conversation with the adolescent, during which you let him know that he is not alone with the problem of opioid abuse. You speak with him about the risks of continued use and encourage him to talk with his family. You facilitate that conversation and refer him to a local rehabilitation center. The family thanks you for averting a major problem. You thank the young man for being brave, coming forward, and helping make you more aware of the seriousness and pervasiveness of this problem.
Joshua M. Sherman, MD, is a pediatric emergency medicine fellow in the Division of Pediatric Emergency Medicine at Cohen Children’s Medical Center, North Shore–Long Island Jewish Health Systems, in New Hyde Park, New York.
Jared E. Friedman, MD, is a pediatric resident at Cohen Children’s Medical Center.
Joshua A. Rocker, MD, is associate chief of the Division of Pediatric Emergency Medicine and the assistant director of the Pediatric Emergency Medicine Fellowship at Cohen Children’s Medical Center.
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