Opioids: nonmedical use and abuse in older children

Predictors of Safe Prescription Opioid Storage and Participation in Drug Take-Back Events: Results from a Statewide Survey

Improper storage and disposal of prescribed opioids can lead to diversion or accidental poisonings. Studies of emergency department and cancer patients suggest prescription opioids are rarely stored securely or disposed of when unneeded. Safe storage and disposal practices reduce risks for others living in or visiting a household. The purpose of this study is thus to examine prescription opioid storage and participation in drug take-back events among Michigan adults. Participants (N = 702) were recruited through social media advertisements to complete an online survey in July and August 2018. Logistic regression was used to examine correlates of safe storage and disposal. 8.4% (n = 59) of participants reported always keeping opioids locked; 29.8% (n = 209) reported attending a drug take-back event. Black participants and those who believed that illegal drug use was a serious problem had greater odds of locking opioids; participants with higher levels of education or who knew someone who used heroin or misused prescription opioids had lesser odds of locking opioids. Age and race were associated with take-back event participation. Findings identify factors associated with safe prescription opioid storage/disposal and indicate safe storage/disposal seldom occurs. Education and provision of safe storage equipment should be designed for diverse ages, races/ethnicities, and levels of education. Drug take-back events not hosted by law enforcement may have broader appeal, as may those led by Black or other people of color. Wider use of drug donation boxes may facilitate increased disposal among those who do not wish to or cannot attend take-back events.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

The Association Between Admiration of Antisocial Peers and Past 30-Day Opioid Misuse Among Justice-Involved children

AIM

Prevention of illicit or nonmedical opioid use, called opioid misuse (OM) is a key public health concern that requires research on the factors that influence OM initiation among high-risk populations. Justice-involved children (JIC) have more risk factors and fewer resources. Antisocial peers have been linked to adolescent substance abuse and delinquency. However, the association between the admiration of antisocial peers and OM among JIC has not yet been studied. This study hypothesizes that admiration of antisocial peers will be associated with a higher likelihood of OM among Florida JIC.

METHODS

Cross-sectional data on 79,960 JIC from the Florida Department of Juvenile Justice (FLDJJ) were examined. To test the hypothesis, bivariate and multivariate logistic regression analyses were employed. The multivariate models controlled for gender, race, age in 2007, family income, history of mental health, history of depression, and optimism.

RESULTS

Nearly 2.7% of the sample met the criteria for past 30-day OM, and over 75% of those current users admired or somewhat admired their antisocial peers. Compare to JIC who did not admire their antisocial peers, those who had some admiration of antisocial peers were 2.39 times more likely to misuse opioids in the past 30-days and those who admired their antisocial peers were 4.40 times more likely to meet the criteria for past 30-day OM.

CONCLUSIONS

Cultivating positive peer interactions and providing positive peer role models may help to reduce illicit opioid use among JIC.

Opioid prescription patterns for pediatric orthopaedic fracture patients

BACKGROUND

While hospitalizations attributed to opioid poisonings are increasing in the pediatric population, the patterns of prescribing behaviors of health care providers remains unclear. The aims of this study were to identify the opioid prescribing patterns of an orthopaedic team for post-surgical pediatric orthopaedic fracture patients, and to examine whether patient demographics, injury type, and type of providers were associated with the opioid prescribing patterns at discharge.

METHODS

A retrospective chart review was performed among all patients aged 0-18 years undergoing surgery for elbow, forearm, wrist, femur, tibia and ankle fractures between 2014 and 2016 at a large children's hospital. Inclusion criteria were patients with isolated operative fractures involving the elbow, forearm, wrist, femur, tibia or ankle who received an opioid prescription at discharge prescribed by a member of the orthopaedic team. Exclusion criteria included patients discharged without opioids or patients discharged with opioid prescriptions from another medical team.

RESPONSE

1000 unique patients (546 male) were identified, with average age of 7.9 years. The most common fracture was elbow (67.2%), followed by femur (12.4%), ankle (9.4%), forearm (5.8%), wrist (4.6%), and tibia (1.6%). Average dose of opioids prescribed was 28.4 (SD = 11.5) per patient. All prescriptions followed recommended guidelines for each medication. Patients who were older (p < 0.0001) or heavier (p < 0.0001) were prescribed a significantly greater average number of opioid doses. Nurse practitioners wrote 57.0% of the discharge prescriptions, followed by residents (23.0%) and physician assistants (14.5%). Attending surgeons accounted for only 5.5% of prescriptions. Residents and physician assistants prescribed significantly higher average doses than nurse practitioners and attending surgeons (p < 0.0001). Patients receiving liquid opioids received a statistically significant (p < 0.001) smaller number of doses than patients receiving tablets.

CONCLUSIONS

Pediatric orthopaedic trauma patients appear to be receiving generic numbers of opioid pain medication doses after fracture surgery due to universal rather than injury-specific prescribing patterns. Further study is required to determine the appropriate number of doses per injury type.

Opioids in Adolescents' Homes: Prevalence, Caregiver Attitudes, and Risk Reduction Opportunities

OBJECTIVE

The most common source of misused opioids is pain relievers prescribed for family and friends. This study was conducted to assess knowledge, attitudes, and behaviors of adolescents' caregivers regarding prescribed opioids in the home.

METHODS

The self-administered survey was completed by caregivers in the waiting rooms of 12 pediatric practices in the Midwest. Eligibility required living in a home where youth age ≥10 years were frequently present. Out of 793 eligible caregivers, 700 (88.3%) completed the survey, 76.8% of whom were the parent.

RESULTS

Among the 700 caregiver respondents, 34.6% reported opioids in the home (13.6% active prescriptions, 12.7% leftover medications, 8.3% both). Of those with an active prescription, 66.0% intended to keep any leftover medications for future needs (for the patient, 60.1%; for someone else, 5.9%). Of those with leftover medications, 60.5% retained them for the same reason (for the patient, 51.0%; for someone else, 9.5%). Others kept medications unintentionally, either because they never got around to disposing of them (30.6%), they did not know how to dispose of them properly (15.7%), or it never occurred to them to dispose of the medications (7.5%). Many caregivers were unaware that adolescents commonly misuse opioids (30.0%) and use them to attempt suicide (52.3%), and that opioid use can lead to heroin addiction (38.6%). According to the surveys, 7.1% would give leftover opioid medications to an adolescent to manage pain and 5.9% might do so.

CONCLUSIONS

Opioids are prevalent in homes in our community, and many parents are unaware of the risks they pose. Study findings can inform strategies to educate parents about opioid risk and encourage and facilitate timely, safe disposal of unused medications.

School Nurses on the Front Lines of Medicine: Uppers and Downers: The Approach to the Student With Altered Mental Status

Although a student presenting with altered mental status due to substance use may occur infrequently in the school setting, it is of utmost importance to develop a differential diagnosis and to initiate stabilization of the student. This article describes the initial assessment and management of a student presenting with altered mental status, focusing on the differential diagnosis of altered mental status, on the varying presentations associated with common intoxications and ingestions, and on the screening tools available for the detection of depression and substance use.

Social Influence on Adolescent Polysubstance Use: The Escalation to Opioid Use

BACKGROUND

Fewer than 9% of 12-17 year olds in need (∼146,000 of 1.7 million) receive inpatient or outpatient substance abuse recovery services or other mental health services (SAMHSA, 2012). The literature on adolescent addiction is sparse, however, as most published addiction recovery efforts involve adult populations-often college students.

OBJECTIVES

The present study examined social influences on escalating substance use (from tobacco, alcohol, and marijuana use to polysubstance use involving opioids) for students enrolled in recovery high schools.

METHODS

A sample of 31 adolescents enrolled in substance use recovery high schools were surveyed on their patterns of substance use leading to their abuse of opioids.

RESULTS

Youth who begin their substance use as young as age 8 are often pressured by peer culture to do so and come from substance-using families. Their escalation in polysubstance use to a pattern including opioids was also most often attributed to peer influence over several years. Conclusions/Importance: This paper is one of scant few that address patterns of use in high school students. Perhaps most salient from this study are the tertiary prevention implications: similar to their adult counterparts, students enrolled in recovery high school programs are likely from substance-using families and have combined complex constellations of substances including opioids by dint of their relationships with substance-using peers.

American Society for Pain Management nursing position statement: pain management in patients with substance use disorders

The American Society for Pain Management Nursing (ASPMN) has updated its position statement on managing pain in patients with substance use disorders. This position statement is endorsed by the International Nurses Society on Addictions (IntNSA) and includes clinical practice recommendations based on current evidence. It is the position of ASPMN and IntNSA that every patient with pain, including those with substance use disorders, has the right to be treated with dignity, respect, and high-quality pain assessment and management. Failure to identify and treat the concurrent conditions of pain and substance use disorders will compromise the ability to treat either condition effectively. Barriers to caring for these patients include stigmatization, misconceptions, and limited access to providers skilled in these two categories of disorders. Topics addressed in this position statement include the scope of substance use and related disorders, conceptual models of addiction, ethical considerations, addiction risk stratification, and clinical recommendations.

Multigenerational effects of adolescent morphine exposure on dopamine D2 receptor function

RATIONALE

The use and misuse of prescription opiates in adolescent populations, and in particular, adolescent female populations, has increased dramatically in the past two decades. Given the significant role that opioids play in neuroendocrine function, exposure to opiates during this critical developmental period could have significant consequences for the female, as well as her offspring.

OBJECTIVES

In the current set of studies, we utilized the female rat to model the transgenerational impact of adolescent opiate exposure.

METHODS

We examined locomotor sensitization in response to the dopamine D2/D3 receptor agonist quinpirole in the adult male progeny (F1 and F2 generations) of females exposed to morphine during adolescence. All females were drug-free for at least 3 weeks prior to conception, eliminating the possibility of direct fetal exposure to morphine.

RESULTS

Both F1 and F2 progeny of morphine-exposed females demonstrated attenuated locomotor sensitization following repeated quinpirole administration. These behavioral effects were coupled with increased quinpirole-induced corticosterone secretion and upregulated kappa opioid receptor and dopamine D2 receptor (D2R) gene expression within the nucleus accumbens.

CONCLUSIONS

These results suggest significant modifications in response to repeated D2R activation in the progeny of females exposed to opiates during adolescence. Given the significant role that the D2R plays in psychopathology, adolescent opiate exposure could shift the vulnerability of future offspring to psychological disorders, including addiction. Moreover, that effects are also observed in the F2 generation suggests that adolescent opiate exposure can trigger transgenerational epigenetic modifications impacting systems critical for motivated behavior.

American Society for Pain Management nursing position statement: pain management in patients with substance use disorders

The American Society for Pain Management Nursing (ASPMN) has updated its position statement on managing pain in patients with substance use disorders. This position statement is endorsed by the International Nurses Society on Addictions (IntNSA) and includes clinical practice recommendations based on current evidence. It is the position of ASPMN and IntNSA that every patient with pain, including those with substance use disorders, has the right to be treated with dignity, respect, and high-quality pain assessment and management. Failure to identify and treat the concurrent conditions of pain and substance use disorders will compromise the ability to treat either condition effectively. Barriers to caring for these patients include stigmatization, misconceptions, and limited access to providers skilled in these two categories of disorders. Topics addressed in this position statement include the scope of substance use and related disorders, conceptual models of addiction, ethical considerations, addiction risk stratification, and clinical recommendations.