Opioid Addiction: Pediatric Collection

The opioid epidemic, with devastating effects on individuals, families, and children, is on those of us who have prescribed, and in many cases overprescribed, opioid medications, and the regulatory and professional organizations that, unwittingly, were a primary cause of this national tragedy. Of course, intentions were good, and a reaction to the decades-old problem of undertreating pain in our patients. But, as frequently happens, the pendulum swung too far in the other direction. Spurred on by catch phrases such as “opiophobia” and “pain as the fifth vital sign,” and implicitly encouraged by the 2000 Joint Commission on Accreditation of Healthcare Organizations standards for pain management, healthcare providers wrote prescriptions for opioids at an ever-increasing rate.^1–3 In 1991, 76 million prescriptions for opioids were dispensed in the United States. This number increased every year through 2012 when 259 million prescriptions were written, or roughly one bottle of opioid analgesics for every adult in the United States.^4,5

Prior to the onset of the current opioid epidemic there had been a general belief, supported by some evidence, that therapeutic use of opioid analgesics rarely led to addiction.¹ While this might be generally true (depending on the definition of “rarely”), the converse is not. The authors of a study published in 2014 reported that 75% of heroin-dependent adults who began abusing opioids during the decade 2000–2010 started by abusing prescription opioids.⁶ Concurrent with the increase in prescriptions for opioids has been an increase in heroin use in the United States; between 2007 and 2012 the estimated number of heroin users increased from 373,000 to 680,000, a 76% increase.⁷ Most tragically, the rate of death from opioid overdoses tripled between 2000 and 2014, with 28,647 deaths in 2014 attributed to opioid overdoses.⁸ In 2015, the number of deaths from opioid overdoses in the United States reached 33,091.⁹

The articles in this collection focus on the manifestations of the opioid epidemic in children and adolescents. Among the many highlights is a study by Patrick et al¹⁰ documenting an increase in the rate of neonatal abstinence syndrome (NAS) from 6.0/1,000 births in 2009 to 10.7/1,000 births in 2011 among newborns enrolled in the Tennessee Medicaid program. In another study included in the collection, Miech et al¹¹ found that legitimate use of prescription opioids before high school graduation was associated with a 33% increased risk of misuse subsequently. On a more positive note is a report by Veliz et al¹² that suggests that daily participation in sports and exercise by adolescents may be protective against nonprescription opioid and heroin use.

Overall, there is much food for thought in this collection. The healthcare “industry” helped cause the current opioid epidemic, and it’s up to healthcare professionals to help end it.

—James A Taylor, MD

Editor-in-Chief, AAP Grand Rounds

A print edition of this collection is available at shopAAP.

References

1.            Baker DW. History of The Joint Commission’s pain standards: lessons for today’s prescription opioid epidemic. JAMA. 2017;317:1117–1118

2.            Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA. 2000;284:428–429

3.            Atkinson TJ, Schatman ME, Fudin J. The damage done by the war on opioids: the pendulum has swung too far. J Pain Res. 2014;7:265–268

4.            Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65:1–49

5.            National Institute on Drug Abuse. America's addiction to opioids: heroin and prescription drug abuse. National Institute on Drug Abuse Web site. https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed December 19, 2017

6.            Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71:821–826

7.            Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary and National Findings, NSDUH Series H-46. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. HHS Publication (SMA) 13-4795

8.            Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378–1382

9.            Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65:1445–1452

10.          Patrick SW, Dudley J, Martin PR, et al. Prescription opioid epidemic and infant outcomes. Pediatrics. 2015;135:842–850

11.          Miech R, Johnston L, O’Malley PM, Keyes KM, Heard K. Prescription opioids in adolescence and future opioid misuse. Pediatrics. 2015;136:e1169–e1177

12.          Veliz P, Boyd CJ, McCabe SE. Nonmedical prescription opioid and heroin use among adolescents who engage in sports and exercise. Pediatrics. 2016;138(2):e20160677