The numbers and statistics are horrifying: an estimated 64,000 of deaths in 2017 and almost 260,000 ED visits for opioid overdoses in 2015. Opioid prescriptions are down, but deaths are rising. Lives are being ruined, communities ripped apart, and increasingly deadly street drugs are flooding all corners of the USA. It is all terrible, but realistically what can we do about it?
Since, we are often not the ones writing the prescriptions, or following the patients, it may seem that our role is limited. But we are the most knowledgeable about the pharmacology, pharmacogenomics, use, misuse, side effects, benefits and contraindications of opioids. We are involved in pain research, developing new and better treatments, dissecting molecular and biochemical responses. and exploring new drugs. We understand that while opioids are a very important part of pain management, they are not the only part. As experts we can share our knowledge. One example is the work done by the American Academy of Pediatric Section on Anesthesiology and Pain Medicine (AAP SOA). We became interested in studying pediatric opioid usage in greater detail and while not earth shattering, our work has contributed significantly to the conversation of opioid abuse in children.
Many pediatric physicians did not think the opioid crisis was their issue, these problems did not occur in their patients. However, several studies have shown that even in pediatrics, prescribers write for more analgesic medication than is likely to be required by the patient. Families often weren't counseled about safe storage or disposal of these medications, making them available for anyone who might visit their homes. One study revealed that 87% of pediatric patients discharged from a university hospital received a prescription for narcotic pain medication. Over 90% of these prescriptions were filled, but only 60% were used. Most families had NOT been counselled on safe disposal. Only 5% of families disposed of unused medications properly, and 50% of families had teenagers in the house. After two weeks, families had on average 36 tablets (range 0-95) or 67 ml (range 0-567 ml) of prescription opioids left over. Another study in children receiving morphine after surgery in Montreal noted that 1431 doses were ordered, and only 131 doses (9.2%) were administered. Despite better counseling in Canada, 65% of respondents stored the unused morphine in their kitchens. Another study, Opioid Poisoning Hospitalization in Children, revealed a twofold increase in hospitalization over the past 16 years due to opioid poisoning in children. While the increase occurred in all age groups, it occurred more frequently in children younger than 4 and in adolescents. Among the top prescribers of opioids to children are pediatricians, dentists, otolaryngologists, orthopedic surgeons, nurse practitioners, and physician assistants.
Data from Monitoring the Future, a group that studies ongoing attitudes and behaviors in youth, revealed that over the past year the annual prevalence of using OxyContinÒ and VicodinÒ without a doctor’s orders increased to approximately four percent by 12th grade. There was very little correlation between family socioeconomic status. education, race, ethnicity and drug use. Teenagers often reported trying these drugs in 9th or 10th grade and obtaining them from leftover prescriptions. Approximately 40% of high-school seniors find narcotics “easy or moderately easy” to obtain. Their sources are quoted as “from a prescription I had” (35%), “bought from a friend” (32%) or “given for free from a friend or relative” (50%).
The FDA and other organizations recommend storing narcotics and opioids in a locked storage unit that cannot be easily accessed by children on teenagers. Most physicians and pharmacists do not counsel families, and surveys show that the majority of families do not store medications in a locked area. Many states, cities, pharmacies and communities have “Take Back” programs, where excess medication (including opioids) can be returned for safe disposal. The DEA has a website of local take-back locations, DEA Controlled Substance Public Disposal Locations, but at least in northern California a more up-to-date website is Don't Rush to Flush.
The AAP SOA started with education. We created modules on management of acute and chronic pain for the AAP’s on-line CME platform, PediaLink. We partnered with the AAP’s Committee on Substance Use and Prevention (COSUP) to develop a series of six webinars as part of a Substance Abuse and Mental Health Services Administration (SAMHSA) Grant. These webinars are available on the Provider Clinical Support System-Opioids website.
We presented and passed a resolution at the AAP’s Annual Leadership Forum, committing resources to creating and adapting educational materials. The goal is to educate pediatricians, pediatric specialists, and other health care professionals about the importance of:
- Safe storage and disposal of opioids
- Prescribing appropriate amounts
- Counseling families regarding safe use, storage and disposal of opioids
- Encouraging practitioners to investigate local resources for safe disposal of all medications.
This resolution resulted in updated information on opioids and other medications on the Healthy Children website (an AAP website designed for use by parents), with posters and articles on the subject. There is an ongoing emphasis on opioid education in upcoming annual conferences. There are two clinical guidelines that will be published in the journal Pediatrics and on the AAP website: one on “Acute Pain Management in Children”, currently undergoing review, and one on “Chronic Pain Management”, in preparation. AAP SOA members worked closely with the FDA to review and subsequently recommend against the use of codeine in children (FDA Drug Communication).These are small but important changes.
We need to take the lead in finding solutions to the opioid crisis before more people die, and before well-meaning politicians create laws that may interfere with good medical practice and stigmatize patients and physicians. We have the knowledge and the ability to get involved in whatever capacity we can. We can tailor our anesthetics to minimize the use of unnecessary opioids, we can continue to study optimal pain regimens in the perioperative period. We can collaborate with our surgeons, hospital administration, local and national societies to make sure that patients get the medicines and multimodal treatment they need to recover from acute or chronic pain, while we decrease the opioids available for misuse in our homes and communities. We need to make sure addiction is treated as the disease it is and not unnecessarily criminalized.
The majority of patients exposed to opioids in the OR do not go on to become addicts, but some do. Can we prevent or influence the rate of addiction?
In California multiple new bills concerning opioids have been introduced this year, all requiring careful physician review. There will much more on these bills in the future and the CSA is actively engaged in this process. Stay tuned for more
This article, Controlling the Swing of the Opioid Pendulum, just published in the New England Journal of Medicine, summarizes some of the issues that patients face, and provides excellent perspective and suggestions. Opioids are a problem, but so are other drugs. Sensible solution will require all our expertise.