Mike Greenwald, MD
mgreenw @emory.edu

Even if you have turned off all news sources over the past 2 years it would be hard to escape the urgent alarms regarding opioid misuse in the US. The statistics are remarkable.

• Since 1999, overdose deaths involving opioids quadrupled.¹
• 2000-2015:greater than half a million people died from drug overdoses.
• 91 Americans die every day from an opioid overdose.
• 1999 to 2010: number of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled.^2,3

This is compelling evidence that we have a problem – perhaps some more than others.  Opioid addiction is a frequent challenge for those caring for adults in the Emergency Department with some centers (e.g. rural) seeing more of this than others. Those who care for injured and ill children are left with 2 important questions: (1) What is the evidence regarding opioid addiction in children? (2) To what extent is the management of acute pain in children contributing to an increase in opioid related morbidity and mortality?

You would expect that a large percentage of opioids are prescribed from Emergency Department visits.  That is, after all, the place where we usually go to address severe pain.  Indeed, Emergency Medicine physicians have been targeted as one of the top specialties prescribing opioids. FDA data from 2009 shows that Emergency Physicians prescribe 4.7% of opioids.  However this reflects short acting opioids and the top prescribers are responsible for a far greater percentage: Family Medicine 26.7%, Internists 15.4%, Dentists 7.7%, Orthopedic surgeons 7.7%.⁴In a 2016 study by Chen et al. Emergency Physicians ranked 9^thin opioid prescribing and the top 8 physician groups were responsible for more than 25 times as many opioid prescriptions as Emergency Physicians.⁵ An analysis of opioid prescribing and subsequent heroin indicates that “1 new heroin abuser might result from the administration of opioids to approximately 7,864 patients”.⁶  While prescribing practices by Emergency Physicians are a valid target for analysis and guidance, their contribution to the crisis is not clear.

Even less certain is the pediatric part of this equation. The relationship between opioid administration for pediatric pain and the development of opioid addiction is an uncommon and likely rare event.  In contrast, studies comparing opioid use for children and adults consistently demonstrate that children receive opioids in far lower weight based doses (approximately 50% in most studies) and frequency for similar conditions (e.g. post operative pain, procedural pain, acute pain).⁷

For the past several decades specialists and researchers in pediatric pain have gradually succeeded in dispelling the misconceptions that younger patients do not feel pain and that opioids are more dangerous for them than poorly treated pain.⁷One of the ironies of the current attention to prescribing practices is the change in terminology.  For many years advocates for better pain treatment have urged colleagues to stop using the term “narcotic” when describing opioid use for pain management.  The term has a pejorative connotation that many found counterproductive in treating pain. Now even lay people know the term “opioid” but in the context of opioid misuse.

Regardless of whether or not the administration of opioids to children in severe pain is contributing to an opioid crisis, the care of pediatric patients will no doubt be affected by the response for adult patients. A quick internet image search for “opioid billboard” reveals multiple versions of the one below:

This shocking message may be working. We now see phrases in the literature such as “Emergency Department: The birthplace of opioid addiction” and “Opioid-Free Emergency Departments”.  How will these attitudes and efforts eventually affect the care of your pediatric patients?

Pendulum swings in public opinion are not surprising.  Our challenge is to temper valid concerns with evidenced based approaches and thoughtful analysis to effectively address problems without creating new ones. Pediatricians need to be front and center in tackling these concerns and not cede that role to those with less expertise and perspective.

The first step is improved education and research. Who is at risk for addiction (e.g. age, co-morbidities)? Where are the misused opioids coming from (e.g. valid prescriptions vs illicit production or diversion)? Physicians who prescribe opioids should have a clear understanding of the pros and cons of opioids for different conditions and the difference between opioid tolerance, dependence, and addiction. Opioid tolerance and sometimes dependence is seen in the setting of regular use of opioids for many consecutive days. Opioid addiction in pediatrics remains a rare condition.

We can lower the risk of diversion by reducing the number of pills prescribed to adequately control severe acute pain without prohibiting the limited use of these medications in appropriate circumstances.  While individual experiences will vary, it is not unreasonable to anticipate a few days of moderate-severe pain after an acute injury or painful procedure.  In many cases regular use of ibuprofen (10mg/kg/dose q6hrs) supplemented with hydrocodone (0.15mg/kg/dose q4hrs prn) is a safe and effective way of getting through this period. Heed the phrase: The Right Tool for the Right Job.  Just as using opioids for less than severe pain introduces unnecessary risk, relying soley on low potency analgesics such as NSAIDs for severe pain will result in needless suffering and undermine the relationship with our patients and their families.

Finally, we can draw lessons from similar challenges in changing physician behavior such as the efforts to reduce inappropriate antibiotic use and ionizing radiation from unnecessary CT scans.  Like antibiotics and CT scans, opioids are an important tool for patient care that have a role for specific indications.  There is no doubt that creating guidelines for opioid use will present unique challenges as pain is ultimately a subjective data point and pain experiences are highly multi-factorial. That challenge, however, is not insurmountable and calls for a nuanced approach that addresses the concerns of patient, clinician, and society.

References

1. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.
2. US Department of Justice. Automation of Reports and Consolidated Orders System (ARCOS). Springfield, VA: US Department of Justice, Drug Enforcement Administration (DEA); 2011.
3. Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999—2008.MMWR 2011; 60(43):1487-1492.
4. Greene J. Amid Finger-Pointing for an Overdose Epidemic, Emergency Physicians Seek Pain Control Alternatives. Ann Emer Med 2016; (68;2) 17A-20A.
5. Chen JH et al. Distribution of Opioids by different medicare prescribers. JAMA Int Med. 2016;176;259-261.
6. Yealy DM and Green SM. Opioids and the Emergency Physician: Ducking Between Pendulum Swings. Annals Emerg Med 2016;68(2) 209-212.
7. Finley GA and McGrath PJ (eds). Acute and Procedural Pain in Infants and Children. Seattle: IASP Press, 2001; 151, 159-160.