US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016

Racial disparities in opioid prescriptions for fractures in the pediatric population

BACKGROUND AND OBJECTIVES

Racial disparities have been well documented in literature regarding pain management. However, few studies have focused on its effect in the pediatric population. This study seeks to examine the relationship between race and opioid prescription patterns for children with fractures.

METHODS

A retrospective study was conducted by reviewing all analgesic prescriptions of discharged pediatric patients (ages 0-21, median 10 years) from a large children's hospital over a five-year period. Multiple logistic regression analysis was applied to examine racial differences in opioid prescriptions for patients with long bone fractures after adjusting for sex, age, length of stay, and payer type.

RESULTS

58,402 analgesic prescriptions were reviewed in this study; 5061 were given for the primary discharge diagnosis of "fracture" of any bone. Overall, 52% of analgesics prescribed for this diagnosis were opioid medications. The relative frequency of opioid prescriptions was 48.7% in Hispanic White patients and 63.1% in non-Hispanic White patients. The odds ratio for non-Hispanic White patients to be prescribed an opioid medication was 1.44 (CI 1.20-1.73) compared to Black patients and to Hispanic White patients after adjustment for sex, age, length of hospital stay, and payer type. The same racial disparity pattern was observed in patients regardless of long bone fracture location.

CONCLUSIONS

Racial bias is suggested in opioid prescription patterns, even in the pediatric population, which may have untoward negative downstream effects. This study delineates the need for improved and standardized methods to adequately treat pain and reduce variations in prescriber habits.

Trends in Childhood Poison Exposures and Fatalities: A Retrospective Secondary Data Analysis of the 2009-2019 U.S. National Poison Data System Annual Reports

Despite significant prevention efforts, childhood poison exposures remain a serious public health challenge in the United States. This study aimed to assess annual trends of pharmaceutical vs. non-pharmaceutical poison exposures in the US among children 0-19 years and compare the odds of death by children's age group. Poison exposure and fatality data were retrospectively extracted from 2009 to 2019 National Poison Data System (NPDS) annual reports for children in all reported age groups. Overall, there was a significant reduction in the annual population-adjusted poison exposures in children (annual percentage change = -2.54%, 95% CI = -3.94% to -1.15%, p < 0.01), but not in poisoning-related fatalities. Children 0-5 had similar odds of dying from exposure to non-pharmaceuticals vs. pharmaceuticals. The odds of children 6-12 dying from non-pharmaceuticals vs. pharmaceuticals was 2.38 (95% CI = 1.58, 3.58), χ² = 18.53, p < 0.001. In contrast, the odds of children 13-19 dying from pharmaceuticals vs. non-pharmaceuticals was 3.04 (95% CI = 2.51, 3.69), χ² = 141.16, p < 0.001. Suicidal intent accounted for 40.63% of pharmaceutical deaths in children 6-12, as well as 48.66% of pharmaceutical and 31.15% of non-pharmaceutical deaths in children 13-19. While a significant decline in overall childhood poison exposures was reported, a decrease in poisoning-related fatalities was not observed. Children in different age groups had contrasting relative odds of death from pharmaceutical and non-pharmaceutical exposures. Among older children, a greater proportion of poisoning-related deaths was due to intentional suicide. These findings provide evidence of age-specific trends in childhood poison exposure risk and directions for future poison prevention efforts and behavioral health partnerships.

Associations between insufficient sleep and prescription opioid misuse among high school students in the United States

STUDY OBJECTIVES

The aim of this study was to estimate the association between insufficient sleep and prescription opioid misuse among US high school students.

METHODS

Participants were 6,884 high school students who self-reported on sleep duration and prescription opioid misuse in the 2019 Youth Risk Behavior Survey. Sleep duration was categorized by the Youth Risk Behavior Survey according to the American Academy of Sleep Medicine guidelines as follows: recommended sleep duration (8-9 hours) vs insufficient sleep (< 8 hours). Participants also reported whether they had any prescription opioid misuse during their lifetime and whether they had prescription opioid misuse within the past 30 days.

RESULTS

Most (79.4%) participants reported sleeping less than 8 hours per night. Among all youth, 12.9% reported lifetime prescription opioid misuse and 6.2% reported current prescription opioid misuse. Prevalence of both lifetime and current opioid medication misuse was higher among those also reporting insufficient sleep compared to those reporting recommended sleep duration (14.3% vs 7.7%, P < .0001 for lifetime misuse and 6.6% vs 4.3%, P = .0091 for current misuse). In multivariate models, insufficient sleep was associated with an increased odds of lifetime prescription opioid misuse (adjusted odds ratios = 1.4; 95% confidence interval, 1.1-1.2; P = .006); however, we did not find an association between sleep duration and current prescription opioid misuse in multivariate analysis.

CONCLUSIONS

Sleep duration is associated with lifetime opioid misuse among US youth. Longitudinal studies are needed to test whether causal relationships exist, and to understand biobehavioral mechanisms that underlie associations between sleep deficiency and opioid misuse in adolescents.

CITATION

Groenewald CB, Rabbitts JA, Tham SW, Law EF, Palermo TM. Associations between insufficient sleep and prescription opioid misuse among high school students in the United States. J Clin Sleep Med. 2021;17(11):2205-2214.

Simultaneous Benzodiazepine and SSRI Initiation in Young People With Anxiety Disorders

Objective: There are potential risks and benefits of combining benzodiazepine (BZD) and selective serotonin reuptake inhibitor (SSRI) therapy at anxiety disorder treatment onset. We investigated how often adolescents and young adults with anxiety disorders simultaneously initiate BZD treatment with SSRI treatment and examined whether SSRI treatment duration varies by simultaneous BZD initiation.

Methods: In a United States commercial claims database (January 2008-December 2016), we identified adolescents (10-17 years) and young adults (18-24 years) with ICD-9-CM/ICD-10-CM anxiety disorder diagnoses initiating SSRI treatment, without past-year SSRI and BZD treatment. We defined simultaneous initiation as filling a new BZD prescription on the date of SSRI initiation. We estimated time to SSRI treatment discontinuation and used stabilized inverse probability of treatment weighting for adjusted estimates.

Results: The study included 94,399 adolescents and 130,971 young adults initiating SSRI treatment with an anxiety disorder. Four percent of adolescents and 17% of young adults simultaneously initiated BZD treatment, varying by age, anxiety disorder, comorbidities, health care utilization, and provider type. Simultaneous BZD initiation among SSRI initiators declined from 2008 to 2016. SSRI treatment duration was similar in initiators of simultaneous therapy vs SSRI monotherapy: ≥ 6 months in adolescents (55% vs 56%, respectively) and in young adults (39% vs 40%). Nine percent of simultaneous initiators continued BZDs for ≥ 6 months.

Conclusions: Simultaneous initiation of BZD and SSRI treatment is relatively common in young adults with anxiety disorders and was not associated with longer SSRI persistence. Given risks of BZD treatment, potential benefits and risks of adding a BZD at SSRI treatment initiation must be carefully weighed.

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?

Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child's care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child's pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ≥12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child's opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ≤ 12 years old with burns that cover ≥3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

A Review of Behavioral Therapies in Adolescents with Opioid Use Disorder

A growing evidence base supports the use of medication to treat opioid use disorder (OUD) in adolescents, but little is known about behavioral therapies for adolescents with OUD. A systematic review using PRISMA methodology was conducted on behavioral therapy for adolescent OUD. Only three studies were identified. Combined evidence from two studies indicates initial efficacy of the Adolescent-Community Reinforcement Approach, motivational enhancement therapy, and cognitive-behavioral therapy for reducing opioid use. The only group therapy identified, which involved adolescents and their parents, demonstrated improvement in participants' knowledge of relapse-prevention strategies, drug-refusal skills, and overall psychosocial functioning. Additional studies that included behavioral therapy but that did not specifically test its efficacy are also highlighted to expand the understanding of the small literature base. This review highlights the sparse evidence base for these therapies in this population. In addition, we highlight promising areas for future research and include evidence from the adult literature that may inform that research. Studies on behavioral therapies that utilize randomized, controlled trials for this population are imperative.

Morphine or hydromorphone: which should be preferred? A systematic review

OBJECTIVE

To systematically review available paediatric literature on comparisons between morphine (Mo) and hydromorphone (Hm), to guide clinicians to rationally use these medications.

DESIGN

Systematic review within four databases for all studies published from 1963 to July 2019.

SETTING

All paediatric settings.

ELIGIBILITY

All studies comparing Mo to Hm in individuals younger than 21 years.

MAIN OUTCOME MEASURES

The primary outcome was to compare clinical efficacy and side effects of Mo and Hm. The secondary outcomes were the comparison of pharmacokinetic profiles and the description of predefined Mo to Hm conversion ratios used across the paediatric literature.

RESULTS

Among 754 abstracts reviewed, 59 full-text articles met inclusion criteria and 24 studies were included in the analysis: 4 studies compared pharmacodynamics of Mo and Hm and 20 studies reported the use of a predefined Mo to Hm conversion ratio. Most studies had a poor methodological quality. Available evidence suggests that, when given intravenously, the equianalgesic ratio of Mo to Hm is 5:1. Intravenous administration with this ratio results in a similar rate of adverse effects, including pruritus and nausea. The epidural administration with a ratio of 10:1 results in more pruritus and urinary retention with Mo than Hm. Pharmacokinetic data were reported in only one study. A wide range of pre-established ratios for different routes of administration were reported, but few were based on evidence.

CONCLUSION

Current literature does not permit a rational choice between Mo and Hm. A ratio of 5:1 seems adequate for intravenous administration and leads to a similar rate of adverse effects.

COVID-19 and Substance Use in Adolescents

Studies have yielded mixed findings regarding changes in adolescent substance use during the COVID-19 pandemic; some report increased alcohol and cannabis use, others show less binge drinking and vaping behaviors, and others no change. In 2019, only 8.3% of the 1.1 million adolescents with a substance use disorder received specialized treatment. Treatment rates for 2020 have not yet been published. Stay-at-home orders and social distancing guidelines put into place in March 2020 caused the partial closure of many outpatient substance use clinics. The implications of this treatment suspension and special considerations for working with adolescents during stay-at-home orders are discussed.

The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'?

RATIONALE

Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis.

METHODS

The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential.

RESULTS

The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables.

LIMITATIONS

The analysis suggests associations not causality.

CONCLUSION

The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.

Temporal Trends in Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US From 2006 to 2018

IMPORTANCE

Prescription opioids are involved in more than half of opioid overdoses among younger persons. Understanding opioid prescribing practices is essential for developing appropriate interventions for this population.

OBJECTIVE

To examine temporal trends in opioid prescribing practices in children, adolescents, and younger adults in the US from 2006 to 2018.

DESIGN, SETTING, AND PARTICIPANTS

A population-based, cross-sectional analysis of opioid prescription data was conducted from January 1, 2006, to December 31, 2018. Longitudinal data on retail pharmacy-dispensed opioids for patients younger than 25 years were used in the analysis. Data analysis was performed from December 26, 2019, to July 8, 2020.

MAIN OUTCOMES AND MEASURES

Opioid dispensing rate, mean amount of opioid dispensed in morphine milligram equivalents (MME) per day (individuals aged 15-24 years) or MME per kilogram per day (age <15 years), duration of prescription (mean, short [≤3 days], and long [≥30 days] duration), high-dosage prescriptions, and extended-release or long-acting (ER/LA) formulation prescriptions. Outcomes were calculated for age groups: 0 to 5, 6 to 9, 10 to 14, 15 to 19, and 20 to 24 years. Joinpoint regression was used to examine opioid prescribing trends.

RESULTS

From 2006 to 2018, the opioid dispensing rate for patients younger than 25 years decreased from 14.28 to 6.45, with an annual decrease of 15.15% (95% CI, -17.26% to -12.99%) from 2013 to 2018. The mean amount of opioids dispensed and rates of short-duration and high-dosage prescriptions decreased for all age groups older than 5 years, with the largest decreases in individuals aged 15 to 24 years. Mean duration per prescription increased initially for all ages, but then decreased for individuals aged 10 years or older. The duration remained longer than 5 days across all ages. The rate of long-duration prescriptions increased for all age groups younger than 15 years and initially increased, but then decreased after 2014 for individuals aged 15 to 24 years. For children aged 0 to 5 years dispensed an opioid, annual increases from 2011 to 2014 were noted for the mean amount of opioids dispensed (annual percent change [APC], 10.58%; 95% CI, 1.77% to 20.16%) and rates of long-duration (APC, 30.42%; 95% CI, 14.13% to 49.03%), high-dosage (APC, 31.27%; 95% CI, 16.81% to 47.53%), and ER/LA formulation (APC, 27.86%; 95% CI, 12.04% to 45.91%) prescriptions, although the mean amount dispensed and rate of high-dosage prescriptions decreased from 2014 to 2018.

CONCLUSIONS AND RELEVANCE

These findings suggest that opioid dispensing rates decreased for patients younger than 25 years, with decreasing rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, opioids remain readily dispensed, and possible high-risk prescribing practices appear to be common, especially in younger children.

Opioid use disorder and overdose among youth following an initial opioid prescription

BACKGROUND AND AIMS

Some adolescents and young adults (termed "youth") prescribed an opioid will develop opioid use disorder or experience overdose. This study aimed to identify patient and prescription characteristics associated with subsequent risk of opioid use disorder or overdose during the year after an opioid is first dispensed.

DESIGN

Retrospective cohort study.

SETTING

Commercial health insurance claims in a large United States (US) database from 2006 to 2016.

PARTICIPANTS

Youth age 11 to 25 years filling an initial opioid prescription (n = 3 278 990).

MEASUREMENTS

The primary outcome was development of an 'opioid-related complication' (a diagnosis of opioid use disorder or opioid-related overdose) during the subsequent 12 months. Exposures of interest were patient (sociodemographic information, and physical and mental health diagnoses) and prescription characteristics (opioid formulation, dose, and duration).

FINDINGS

Among youth filling an initial opioid prescription, median age was 18 years (interquartile range [IQR] = 16-21) and 56.1% were female. During the subsequent 12 months, 10 405 (0.3%) youth experienced an opioid-related complication. Conditions associated with increased risk included mood/anxiety disorders (adjusted relative risk [aRR] = 4.45; 95% CI = 4.25-4.66) and substance use (aRR = 20.77; 95% CI = 19.74-21.84). Comorbid substance use disorders were present among 72.8% of youth experiencing an opioid-related complication and included alcohol (33.4%), cannabis (33.0%), nicotine (43.2%), and other substance use disorders (75.5%). Long-acting opioids (aRR = 2.59; 95% CI = 2.18-3.09) and longer durations were associated with increased risk (7-14 days: aRR = 1.15; 95% CI = 1.08-1.22; ≥15 days: aRR = 1.96; 95% CI = 1.80-2.12) compared with short-acting formulations and durations ≤3 days, respectively.

CONCLUSIONS

Among United States youth, complications after an initial opioid prescription appear to be relatively rare and appear to be associated with mood/anxiety disorders, substance use, comorbid substance use disorders, and prescriptions involving long-acting opioids or long durations.

Cumulative protective factors are associated with decreased risk for prescription opioid misuse among high school students

BACKGROUND

Multiple protective factors at the individual and environmental levels have been associated with prescription opioid misuse (POM) among adolescents. The literature may benefit by extending this research to consider the association between cumulative protective factors and current (ie, within the past 30 days) POM.

METHODS

The 2017 Virginia Youth Survey (part of the Youth Risk Behaviour Surveillance System) (N=3697) was used to investigate recent POM and the presence of individual and cumulative protective factors among high school students. Youth were asked to indicate whether they had engaged POM within the past 30 days. A set of protective factors representing youths' internal assets (eg, aspirational plans for education) and external resources (eg, family meals, safe school environment) were investigated as predictors of current POM, followed by testing of a cumulative protective factor score. Logistic regression models estimated ORs and 95% CIs.

RESULTS

When including demographics and risk factors in the model, none of the individual protective factors were significantly associated with current POM. Alternatively, the cumulative protective factor score was significantly associated with a decrease in the odds of current POM.

CONCLUSIONS

The cumulative protective factor score was significantly associated with a decrease in the odds of current POM among high school students in Virginia. Programmes designed to provide multiple forms of support may be effective strategies for preventing current POM.

A Multivariable Model of Parent Satisfaction, Pain, and Opioid Administration in a Pediatric Emergency Department

INTRODUCTION

Children and adolescents are not impervious to the unprecedented epidemic of opioid misuse in the United States. In 2016 more than 88,000 adolescents between the ages of 12-17 reported misusing opioid medication, and evidence suggests that there has been a rise in opioid-related mortality for pediatric patients. A major source of prescribed opioids for the treatment of pain is the emergency department (ED). The current study sought to assess the complex relationship between opioid administration, pain severity, and parent satisfaction with children's care in a pediatric ED.

METHODS

We examined data from a tertiary pediatric care facility. A health survey questionnaire was administered after ED discharge to capture the outcome of parental likelihood of providing a positive facility rating. We abstracted patient demographic, clinical, and top diagnostic information using electronic health records. Data were merged and multivariable models were constructed.

RESULTS

We collected data from 15,895 pediatric patients between the ages of 0-17 years (mean = 6.69; standard deviation = 5.19) and their parents. Approximately 786 (4.94%) patients were administered an opioid; 8212 (51.70%) were administered a non-opioid analgesic; and 3966 (24.95%) expressed clinically significant pain (pain score >/= 4). Results of a multivariable regression analysis from these pediatric patients revealed a three-way interaction of age, pain severity, and opioid administration (odds ratio 1.022, 95% confidence interval, 1.006, 1.038, P = 0.007). Our findings suggest that opioid administration negatively impacted parent satisfaction of older adolescent patients in milder pain who were administered an opioid analgesic, but positively influenced the satisfaction scores of parents of younger children who were administered opioids. When pain levels were severe, the relationship between age and patient experience was not statistically significant.

CONCLUSION

This investigation highlights the complexity of the relationship between opioid administration, pain severity, and satisfaction, and suggests that the impact of opioid administration on parent satisfaction is a function of the age of the child.

Prescription Opioid Misuse and Sports-Related Concussion Among High School Students in the United States

STUDY OBJECTIVE

Concussion is highly prevalent in adolescents and associated with a higher risk of substance use. With the rising use of opioids among adolescents, one form of substance use of concern is the misuse of prescription opioids. This study aimed to examine the association between a history of sports-related concussion in the past year and current prescription opioid misuse among high school students in the United States.

SETTING

Secondary data analysis from the 2019 Youth Risk Behavior Survey.

PARTICIPANTS

Nationally representative sample of high school students (n = 7314).

DESIGN

Cross-sectional study.

MAIN MEASURES

Participants were asked whether they experienced any concussions related to sports or being physically active during the past 12 months and whether they had any prescription opioid misuse within the past 30 days.

RESULTS

Among this cohort, 14.0% reported sustaining a concussion in the past 12 months and 6% reported current prescription opioid misuse. The prevalence of prescription opioid misuse was higher among those with a history of concussion (9.9%) than among those without concussion (5.5%, P = .002). Controlling for covariates (sex, race/ethnicity, other substance use, depressive symptoms), the odds of prescription opioid misuse was 1.5 times higher for adolescents with concussion than those without (adjusted odds ratios [aOR] = 1.5; 95% CI, 1.0-2.3; P = .029).

CONCLUSION

Concussion was associated with prescription opioid misuse among the US youth, even after accounting for depressive symptoms and other substance use. Longitudinal studies are needed to test causal relationships and understand biobehavioral mechanisms that underlie associations between concussion and opioid misuse in adolescents.

Opioid Prescribing to US Children and Young Adults in 2019

BACKGROUND

Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years.

METHODS

We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with ≥1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by ≥1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the ≥95th percentile.

RESULTS

Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had ≥1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of ≥50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by ≥1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions.

CONCLUSIONS

Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.

Pediatric Urologic Surgery: Reducing Opioid Use

Adequate pain management is important for successful postoperative recovery after any surgical procedure. Unfortunately, the USA and many other parts of the world are in the midst of an opioid epidemic, and healthcare providers are thus tasked with balancing the comfort and recovery of their patients after an operation against the individual and societal harms of the over-prescription of opioids. The goal of this article is to discuss the range of opioid formulations currently in use, examine why this may be problematic, and explore alternatives that provide similar efficacy and may improve overall safety in the pediatric population after urologic surgery. Improving the way opioids are prescribed through clinical practice guidelines as well as considering alternatives to opioids can ensure patients have access to safer and more effective pain treatments and potentially reduce opioid misuse.

Examining the Effects of Music-Based Interventions on Pain and Anxiety in Hospitalized Children: An Integrative Review

PROBLEM

Children often experience pain and anxiety during a hospital stay. Effective pain and anxiety management plays a crucial role in healing. However, recent literature has highlighted multiple barriers to managing pain and anxiety in children, such as parent and provider fears of the adverse effects of pain and anxiety medications.

ELIGIBILITY CRITERIA

A database search was conducted for articles published between 2009 and 2019 to evaluate the impact of nurse-led, music-based interventions as an adjunct method of pain and anxiety management in hospitalized children. Articles were included if study subjects were ages 0-21 years old, the study used live or recorded music as an intervention, and occurred in an inpatient setting.

SAMPLE

A total of seven randomized control trials and one quasi-experimental study were included for analysis.

RESULTS

There is consistent and significant evidence that music can reduce anxiety in hospitalized children before and during procedures. Results with respect to pain and vital signs, often viewed as the physiologic analogs to pain, were mixed.

CONCLUSIONS

Music-based interventions are safe for hospitalized children. Several studies highlighted the importance of patient preference in selecting music for children. A heavy reliance on pre-recorded audio, delivered via headphones illustrates the feasibility and cost-effectiveness of music-based interventions.

IMPLICATIONS

Nurse-led, music-based interventions have been shown to be an affordable, safe, effective, and feasible alternative for managing anxiety in hospitalized children. Music should be considered as an adjunct therapy to traditional anxiety treatment. Further research is needed to determine the effects of music on pain.

Improving Treatment Together: a protocol for a multi-phase, community-based participatory, and co-design project to improve youth opioid treatment service experiences in British Columbia

Background

Opioid use is one of the most critical public health issues as highly potent opioids contribute to rising rates of accidental opioid-related toxicity deaths. This crisis has affected people from all age groups, including youth (ages 15–24) who are in a critical developmental period where the stakes of opioid use are especially high. Efforts to reduce the significant harms of opioid use have focused on the expansion of evidence-based treatments, including medications for opioid use disorder (e.g. buprenorphine). While these treatments are unequivocally life saving, recent evidence suggests that they may not align with youths’ needs. Accordingly, the ‘Improving Treatment Together’ (ITT) project has been designed with the aim to improve youths’ opioid treatment service experiences and outcomes by co-developing, implementing, and measuring youth-centred opioid use treatment service innovations. This manuscript describes the protocol for this multi-phase project.

Methods

The ITT project follows community-based participatory research (CBPR) and strategically integrates co-design processes throughout its four phases. Upon establishing a project partnership between national, provincial and community-based organizations, Phase 1 follows four core elements of human-centred co-design (empathy, needs identification, ideation, prototyping) in nine separate workshops. These workshops will be held in four diverse communities with youth, caregivers and service providers who have accessed or delivered opioid treatment services. Phase 1 will culminate in the co-production of opioid treatment service innovations to be considered by the project’s partners for further co-development, pilot testing, and wider implementation during the remaining phases of the project. Throughout each phase, the project will collect and analyse both qualitative and quantitative research and evaluation data to determine the project’s impact.

Discussion

This protocol provides a detailed description of the ITT project, with an emphasis on the project’s application of co-design and CBPR processes, the planned research and implementation procedures, and the establishment of a unique partnership. To our knowledge, this is one of the first projects to integrate these participatory processes to the design, implementation and measurement of youth-centred opioid treatment services. Embedding these processes throughout each phase of the project will strengthen the relevance and feasibility of the project’s service delivery innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00261-7.

The impact of patient age and procedure type on postoperative opioid use following ambulatory pediatric urologic procedures

PURPOSE

The aim of this study is to determine whether patient age and procedure type are associated with duration of opioid use in pediatric patients undergoing ambulatory urologic procedures.

METHODS

We retrospectively reviewed pediatric patients who underwent outpatient urologic procedures from 2013 to 2017. At postoperative visits, parents reported the number of days their child took opioid pain medication. Factors associated with duration of opioid use were evaluated using negative binomial regression models.

RESULTS

805 patients were included: 320 infants (39.8%), 430 children (53.4%), and 55 adolescents (6.8%). Overall mean length of opioid use was 1.7 (± 2.6) days. On average, infants used opioids for the shortest duration: 1.5 (± 2.3) days, followed by children: 1.7 (± 2.5) days, and adolescents: 3.1 (± 4.6) days. In adjusted models, adolescents used opioids for 85.2% longer (95% CI 13.1-161.8%; p < 0.001) than children and infants used opioids for 19.4% shorter duration (95% CI 0.4-34.7%; p = 0.05) than children. Each 1-year increase in age was associated with 6.1% increased duration of opioid use (95% CI 3.9-8.5%; p < 0.0001). Patients who underwent circumcision, hypospadias repair, and penile reconstruction took opioids for 75.9% (95% CI 42.6-117.1%; p < 0.001), 144.2% (95% CI 76.4-238.0%; p < 0.001), and 126.7% (95% CI 48.8-245.3%; p < 0.001) longer respectively than patients who underwent inguinal procedures.

CONCLUSIONS

Increasing age, circumcision, hypospadias repair, and penile reconstruction are associated with increased duration of opioid use.

Emergency department strategies to combat the opioid crisis in children and adolescents

The opioid crisis has greatly affected not only adults but also children as well. As clinicians develop effective approaches to minimize pain and distress in children, the risks and benefits of opioids must be carefully considered. Children of parents with opioid use disorder are also at risk of living in unstable environments, performing poorly academically, engaging in future drug use, and having increased stress, which affects their development before entering adulthood. This statement focuses on the effects of the opioid crisis on children and adolescents and is intended to inform institutional policies, improve education, advocate for evidence-informed guidelines, and improve the care of children affected by the opioid epidemic who are seen in the emergency department.

Receipt of medications for opioid use disorder among youth engaged in primary care: data from 6 health systems

PURPOSE

Little is known about prevalence and treatment of OUD among youth engaged in primary care (PC). Medications are the recommended treatment of opioid use disorder (OUD) for adolescents and young adults (youth). This study describes the prevalence of OUD, the prevalence of medication treatment for OUD, and patient characteristics associated with OUD treatment among youth engaged in PC.

METHODS

This cross-sectional study includes youth aged 16-25 years engaged in PC. Eligible patients had ≥ 1 PC visit during fiscal years (FY) 2014-2016 in one of 6 health systems across 6 states. Data from electronic health records and insurance claims were used to identify OUD diagnoses, office-based OUD medication treatment, and patient demographic and clinical characteristics in the FY of the first PC visit during the study period. Descriptive analyses were conducted in all youth, and stratified by age (16-17, 18-21, 22-25 years).

RESULTS

Among 303,262 eligible youth, 2131 (0.7%) had a documented OUD diagnosis. The prevalence of OUD increased by ascending age groups. About half of youth with OUD had documented depression or anxiety and one third had co-occurring substance use disorders. Receipt of medication for OUD was lowest among youth 16-17 years old (14%) and highest among those aged 22-25 (39%).

CONCLUSIONS

In this study of youth engaged in 6 health systems across 6 states, there was low receipt of medication treatment, and high prevalence of other substance use disorders and mental health disorders. These findings indicate an urgent need to increase medication treatment for OUD and to integrate treatment for other substance use and mental health disorders.

Immunity to Hepatitis B is Undetectable in the Majority of Adolescents and Young Adults Seeking Outpatient Medication Treatment for Opioid Use Disorder

OBJECTIVE

To assess prevalence and predictors of hepatitis B immune status among adolescents and young adults (AYA) seeking outpatient medication treatment for opioid use disorder (MOUD).

STUDY DESIGN

A retrospective medical chart review was conducted of AYA seeking MOUD between January 1, 2013 through December 31, 2015. Inclusion criteria included: diagnosis of opioid use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; received hepatitis serologic testing; and no evidence of prior or current hepatitis B infection. Hepatitis B immunization initiation was defined as a record of at least 1 hepatitis B vaccination; while receipt of at least 3 vaccinations indicated immunization completion. The presence of hepatitis B surface antibody (anti-HBs) was the primary outcome measure.

RESULTS

Of the 193 patients that met eligibility criteria, the presence of anti-HBs was evident in 62 (32.1%). Hepatitis B immunization initiation and completion before presenting for MOUD was documented in 102 (52.9%) and 84 (43.5%). In multivariable logistic regression modeling, hepatitis B immunization initiation after infancy was associated with increased odds of having protective anti-HBs relative to immunization series initiation in infancy (OR 8.96, 95% CI 1.57-51.05). Completion of hepatitis B immunization series after infancy as compared to completion in infancy also increased the odds of protective anti-HBs (OR, 6.68, 95% CI 2.10-21.24).

CONCLUSIONS

Rates of immunity to hepatitis B were low in AYA seeking MOUD. It is important to immunize patients seeking MOUD for hepatitis B and follow up with checks for seroconversion.

Racial and ethnic disparities in opioid use for adolescents at US emergency departments

Background

Racial/ethnic disparities in the use of opioids to treat pain disorders have been previously reported in the emergency department (ED). Further research is needed to better evaluate the impact race/ethnicity may have on the use of opioids in adolescents for the management of pain disorders in the ED.

Methods

This was a cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey from 2006 to 2016. Multivariate models were used to evaluate the role of race/ethnicity in the receipt of opioid agonists while in the ED. All ED visits with patients aged 11–21 years old were analyzed. Races/ethnicities were stratified as non-Hispanic Whites, non-Hispanic Blacks, and Hispanics. In addition to race, statistical analysis included the following covariates: pain score, pain diagnosis, age, region, sex, and payment method.

Results

There was a weighted total of 189,256,419 ED visits. Those visits involved 109,826,315 (58%) non-Hispanic Whites, 46,314,977 (24%) non-Hispanic Blacks, and 33,115,127 (18%) Hispanics, with 21.6% (95% CI, 21.1%-22.1), 15.2% (95% CI, 14.6–15.9%), and 17.4% (95% CI, 16.5–18.2%) of those visits reporting use of opioids, respectively. Regardless of age, sex, and region, non-Hispanic Whites received opioids at a higher rate than non-Hispanic Blacks and Hispanics. Based on diagnosis, non-Hispanic Whites received opioids at a higher rate in multiple pain diagnoses. Additionally, non-Hispanic Blacks and Hispanics were less likely to receive an opioid when reporting moderate pain (aOR = 0.738, 95% CI 0.601–0.906, aOR = 0.739, 95% CI 0.578–0.945, respectively) and severe pain (aOR = 0.580, 95% CI 0.500–0.672, aOR = 0.807, 95% CI 0.685–0.951, respectively) compared to non-Hispanic Whites.

Conclusions

Differences in the receipt of opioid agonists in EDs among the races/ethnicities exist, with more non-Hispanic Whites receiving opioids than their minority counterparts. Non-Hispanic Black women may be an especially marginalized population. Further investigation into sex-based and regional differences are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02715-y.

A Large-Scale Observational Study on the Temporal Trends and Risk Factors of Opioid Overdose: Real-World Evidence for Better Opioids

Background

The USA is in the midst of an opioid overdose epidemic. To address the epidemic, we conducted a large-scale population study on opioid overdose.

Objectives

The primary objective of this study was to evaluate the temporal trends and risk factors of inpatient opioid overdose. Based on its patterns, the secondary objective was to examine the innate properties of opioid analgesics underlying reduced overdose effects.

Methods

A retrospective cross-sectional study was conducted based on a large-scale inpatient electronic health records database, Cerner Health Facts^®, with (1) inclusion criteria for participants as patients admitted between 1 January, 2009 and 31 December, 2017 and (2) measurements as opioid overdose prevalence by year, demographics, and prescription opioid exposures.

Results

A total of 4,720,041 patients with 7,339,480 inpatient encounters were retrieved from Cerner Health Facts^®. Among them, 30.2% patients were aged 65+ years, 57.0% female, 70.1% Caucasian, 42.3% single, 32.0% from the South, and 80.8% in an urban area. From 2009 to 2017, annual opioid overdose prevalence per 1000 patients significantly increased from 3.7 to 11.9 with an adjusted odds ratio (aOR): 1.16, 95% confidence interval (CI) 1.15–1.16. Compared to the major demographic counterparts, being in (1) age group: 41–50 years (overall aOR 1.36, 95% CI 1.31–1.40) or 51–64 years (overall aOR 1.35, 95% CI 1.32–1.39), (2) marital status: divorced (overall aOR 1.19, 95% CI 1.15–1.23), and (3) census region: West (overall aOR 1.32, 95% CI 1.28–1.36) were significantly associated with a higher odds of opioid overdose. Prescription opioid exposures were also associated with an increased odds of opioid overdose, such as meperidine (overall aOR 1.09, 95% CI 1.06–1.13) and tramadol (overall aOR 2.20, 95% CI 2.14–2.27). Examination on the relationships between opioid analgesic properties and their association strengths, aORs, and opioid overdose showed that lower aOR values were significantly associated with (1) high molecular weight, (2) non-interaction with multi-drug resistance protein 1 or interaction with cytochrome P450 3A4, and (3) non-interaction with the delta opioid receptor or kappa opioid receptor.

Conclusions

The significant increasing trends of opioid overdose at the inpatient care setting from 2009 to 2017 suggested an ongoing need for efforts to combat the opioid overdose epidemic in the USA. Risk factors associated with opioid overdose included patient demographics and prescription opioid exposures. Moreover, there are physicochemical, pharmacokinetic, and pharmacodynamic properties underlying reduced overdose effects, which can be utilized to develop better opioids.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-021-00253-8.

Effect of Drug Disposal Kits and Fact Sheets on Elimination of Leftover Prescription Opioids: The DISPOSE Multi-Arm Randomized Controlled Trial

OBJECTIVE

To determine how passively providing informational handouts and/or drug disposal kits affects rates of leftover prescription opioid disposal.

DESIGN

A multi-arm parallel-group randomized controlled trial with masked outcome assessment and computer-guided randomization.

SETTING

Johns Hopkins Health System outpatient pharmacies.

SUBJECTS

Individuals who filled ≥1 short-term prescription for an immediate-release opioid for themselves or a family member.

METHODS

In June 2019, 499 individuals were randomized to receive an informational handout detailing U.S. Food and Drug Administration-recommended ways to properly dispose of leftover opioids (n = 188), the informational handout and a drug disposal kit with instructions on its use (n = 170), or no intervention (n = 141) at prescription pickup. Subjects were subsequently contacted by telephone, and outcomes were assessed by a standardized survey. The primary outcome was the use of a safe opioid disposal method.

RESULTS

By 6 weeks after prescription pickup, 227 eligible individuals reported they had stopped taking prescription opioids to treat pain and had leftover medication. No difference in safe disposal was observed between the non-intervention group (10% [6/63]) and the group that received disposal kits (14% [10/73]) (risk ratio = 1.44; 95% confidence interval: 0.55 to 3.74) or the group that received a fact sheet (11% [10/91]) (risk ratio = 1.15; 95% confidence interval: 0.44 to 3.01).

CONCLUSIONS

These findings suggest that passive provision of a drug disposal kit at prescription pickup did not increase rates of leftover opioid disposal when compared with provision of a fact sheet alone or no intervention. Active interventions may deserve further investigation.

Impact of prescription drug monitoring program mandate on postoperative opioid prescriptions in children

PURPOSE

Prescription drug monitoring programs (PDMPs) have been established to combat the opioid epidemic, but there is no data on their efficacy in children. We hypothesized that a statewide PDMP mandate would be associated with fewer opioid prescriptions in pediatric surgical patients.

METHODS

Patients < 18 undergoing inguinal hernia repair, orchiopexy, orchiectomy, appendectomy, or cholecystectomy at a tertiary children's hospital were included. The primary outcome, discharge opioid prescription, was compared for 10 months pre-PDMP (n = 158) to 10 months post-PDMP (n = 228). Interrupted time series analysis was performed to determine the effect of the PDMP on opioid prescribing.

RESULTS

Over the 20-month study period, there was an overall decrease in the rate of opioid prescriptions per month (- 3.6% change, p < 0.001). On interrupted time series analysis, PDMP implementation was not associated with a significant decrease in the monthly rate of opioid prescriptions (1.27% change post-PDMP, p = 0.4). However, PDMP implementation was associated with a reduction in opioid prescriptions of greater than 5 days' supply (- 2.7% per month, p = 0.03).

CONCLUSION

Opioid prescriptions declined in pediatric surgical patients over the study time period. State-wide PDMP implementation was associated with a reduction in postoperative opioid prescriptions of more than 5 days' duration.

Medication Treatments for Youth and Young Adults With Opioid Use Disorder

Opioid use disorder (OUD) and overdose deaths are increasingly prevalent among youth and young adults; however, the evidence-based medication-assisted treatments (MATs) that have U.S. Food and Drug Administration approval for the treatment of adults are not approved for persons aged 16 to 18 years. New guidelines from the American Society of Addiction Medicine provide information on the risks and benefits of MAT with youth and young adults that help guide decision making. Clinical decisions require a thorough physical and psychiatric evaluation, risk/benefit analysis in treatment planning, and collaboration with youth and young adults to engage support systems. The current article presents an overview of the three available maintenance treatments for youth and young adults with OUD. [Journal of Psychosocial Nursing and Mental Health Services, 59(5), 9-13.].

Diagnosis of Opioid Use Disorder by Youths Assessed in Acute Care Settings in British Columbia, Canada

OBJECTIVES

To describe trends in the number of youths diagnosed with opioid use disorder (OUD) and to identify factors associated with OUD diagnosis in acute care settings.

STUDY DESIGN

Data from a population-based retrospective cohort study with linkage of 6 health administrative databases for 13 009 youth age 12-24 years identified with OUD between 2001 and 2018 in British Columbia, Canada were used to describe annual diagnoses. Using a multiple logistic regression model, we estimated the association between past-year health care utilization and OUD diagnosis in acute settings, controlling for sociodemographic and OUD-related comorbid conditions.

RESULTS

Annual OUD diagnoses quadrupled between 2003 and 2017 (from 326 to 1473). Among the 6579 youth diagnosed with OUD between April 1, 2013 and September 30, 2018, 88.1% had past-year health system contacts. Youth age 12-18 had higher odds of OUD diagnosis in acute care (aOR 2.04; 95% CI 1.78, 2.34). Compared with no health care contact, youth receiving outpatient care only were less likely to be diagnosed with OUD in acute care (aOR 0.69; 95% CI 0.56, 0.84) and those with >1 urgent hospitalization were more likely to be diagnosed with OUD in acute care (aOR 1.87; 95% CI 1.40,2.49).

CONCLUSIONS

More than 88% of youth had past-year health system contacts prior to diagnosis. Those age 12-18 years and with urgent hospitalizations in the year prior to diagnosis were more likely to have OUD diagnosed in acute care settings. Establishing an effective evidence-based system for early detection and intervention among youth with OUD must be a priority.

Personality to Prescription Drug Misuse in Adolescents: Testing Affect Regulation, Psychological Dysregulation, and Deviance Proneness Pathways

Background: Fifteen to 25-year-olds are the age group most likely to misuse prescription drugs. Few studies have tested theory-driven models of adolescent risk for prescription drug misuse. Moreover, rarely are distinct pathways to different forms of prescription drug misuse considered. Methods: We tested mediational paths from personality to mental health symptoms to prescription drug misuse, informed by etiological models of addiction. We specified pathways from particular personality traits to unique forms of prescription drug misuse via specific mental health symptoms. We used semi-longitudinal data collected across two waves of the Co-Venture Trial. Our sample included students from 31 Canadian high schools tested in Grade 9 (n = 3,024) and again in Grade 10 (n = 2,869; 95% retention). Personality (hopelessness, anxiety sensitivity, impulsivity, sensation seeking) was assessed in Grade 9. Mental health symptoms (depression, anxiety, ADHD, conduct disorder) and prescription drug misuse (opioids, sedatives/tranquilizers, stimulants) were assessed at both time points. Results: Consistent with the negative affect regulation model, hopelessness was specifically associated with opioid misuse via depressive symptoms, and anxiety sensitivity was specifically associated with sedative/tranquilizer misuse via anxiety symptoms. Consistent with positive affect regulation, sensation seeking was directly associated with stimulant misuse. Consistent with the psychological dysregulation model, impulsivity was associated with stimulant misuse via ADHD symptoms. And consistent with the deviance proneness model, impulsivity was also associated with unconstrained (i.e., all three forms of) prescription drug misuse via conduct disorder symptoms. Conclusions: Screening for adolescents high in hopelessness, anxiety sensitivity, sensation seeking, or impulsivity and providing them with personality-matched cognitive-behavioral interventions may be helpful in preventing or mitigating prescription drug misuse. Our results point to the specific mental health symptoms that are important to target in each of these personality-matched interventions.

Pediatric opioid fatalities: What can we learn for prevention?

The aim of this study was to highlight 19 cases investigated by the North Carolina Office of the Chief Medical Examiner over the last 12 years involving accidental or undetermined manner of death opioid ingestions leading to fatalities in young children. These pediatric ingestions have closely mirrored the opioid epidemic in adults transitioning from prescription medications to illicit drugs including fentanyl and fentanyl analogues. Unlike a typical adult ingestion for purposes of self-harm or pleasure, poisonings in toddlers and infants are usually the result of curiosity, exploration, a decreased sense of danger, or imitation of adult or older sibling behavior. Eleven of the decedents were between the ages of 8 and 24 months. Among the cases were 12 prescription opioid exposure deaths and 7 illicit drug poisonings. A majority of the decedents were found unresponsive in an unkept home and/or in unsafe sleeping spaces with easy access to drugs or drug materials, which stresses the importance of safe pediatric sleeping conditions. After a complete pathological investigation, several of the cases had physical or scene evidence demonstrating that foil, plastic, or paper small enough to be ingested can contain enough potent opioid to cause death. Details from the toxicological investigation are included for each case to provide postmortem whole blood drug concentrations for forensic practitioners. Accidental pediatric poisonings are preventable. Risk reduction through improving awareness and education of the dangers of opioids is a key factor in mitigating these tragedies.

Correlates and motivations of prescription opioid use among adolescents 12 to 17 years of age in the United States

Despite significant efforts, the opioid crisis remains a pressing health concern affecting adolescents. The primary aim of this study was to describe recent sociodemographic shifts in the opioid epidemic. We examined whether rates of opioid use, including opioid misuse and opioid use disorder among 12 to 17 year olds in the United States, differ according to sociodemographic factors, physical and mental health, and substance use characteristics using data from the 2015 and 2016 National Survey on Drug Use and Health. We also examined motivations for opioid misuse. The study included 27,857 participants. Black, non-Hispanic adolescents were more likely to both use and misuse opioids as compared to white, non-Hispanic adolescents, a clear difference from previous studies. The main motivation for misuse by adolescents was relief of physical pain (50%, 95% confidence interval 46%-54%). Adolescents who reported pain relief as the major reason for misuse had increased odds of substance use as compared to adolescents who did not report any opioid misuse. However, odds for substance use was greatest among adolescents who reported reasons other than pain relief for opioid misuse. National Survey on Drug Use and Health self-report data suggest recent shifts in opioid misuse with minority adolescents appearing to be at increased risk of opioid misuse compared with white adolescents. Relief of physical pain is the most common motivation for opioid misuse.

Management of Adolescents With OUD: A Simulation Case for Subspecialty Trainees in Addiction Medicine and Addiction Psychiatry

Introduction

The opioid epidemic impacts all ages, yet few published medical education curricula exist to train physicians on how to care for opioid use disorder (OUD) in adolescents, a developmental stage where confidentiality protection is appropriate and contributes to quality health care. We developed a simulation-based educational intervention to increase addiction medicine and addiction psychiatry trainees' confidence in managing adolescents with OUD.

Methods

Trainees completed a confidence survey and viewed an educational video covering state-specific confidentiality laws pertinent to treating adolescents with OUD. One week later, trainees participated in a simulated encounter where they described the scope of confidentiality to a trained actor, used the Clinical Opiate Withdrawal Scale to assess symptoms of opioid withdrawal, and explained adolescent-specific OUD medication treatment options. Immediately afterward, trainees completed a self-reflection and satisfaction survey and participated in a debriefing session with a faculty member where they identified learning goals. One month later, they completed the confidence survey to quantify changes in confidence.

Results

Thirty-five fellows (21 male, 14 female) completed the simulation-based educational intervention between 2016 and 2019. When asked to answer yes or no, 96% of participants described the exercise as effective and 100% (n = 26) would recommend it to peers. In addition, learners identified future learning goals, including researching specific topics and seeking out additional opportunities to evaluate adolescents with OUD.

Discussion

Based on our participants' report, this simulation-based educational intervention is an effective teaching method for increasing trainee confidence in managing adolescents with OUD.

The cascade of care for opioid use disorder among youth in British Columbia, 2018

BACKGROUND

Medication for opioid use disorder (MOUD) is associated with substantial reductions in the risk of mortality, and American and Canadian guidelines recommend it as part of the full range of available treatments for youth with opioid use disorder (OUD). We estimated the OUD cascade of care for all adolescents (ages 12-18) and young adults (19-24) with OUD in British Columbia, Canada (BC) in 2018.

METHODS

Using a provincial-level linkage of six health administrative databases, we classified youth with OUD as adolescents (ages 12-18) or young adults (19-24) to compare with older adults (≥25) and described key factors known to influence engagement in health care. The eight-stage cascade of care included diagnosed with OUD, ever engaged in MOUD, recently in MOUD, currently in MOUD, and retained in MOUD for ≥1 month, ≥3 months, ≥12 months, ≥24 months.

RESULTS

We identified 4048 youth diagnosed with OUD as of September 30, 2018 (6.3% of all people with OUD). Most were young adults, aged 19-24 (n = 3602; 89.0% of all youth), a majority of whom were males (n = 1984; 55.1%). In contrast, adolescents diagnosed with OUD (n = 446; 11.0% of all youth) were mostly females (n = 287; 64.4%). Compared to adolescents, there were more young adults diagnosed with OUD ever engaged in MOUD (71.4% v. 36.5%), currently on MOUD (29.3% v. 16.8%), and retained in care for ≥1 year (8.6% v. 2.0%).

CONCLUSIONS

A high proportion of youth aged 12-24 diagnosed with OUD in a health care setting in British Columbia received MOUD yet continued engagement is infrequent, particularly for adolescents. Long-term treatment plans for youth need to consider including MOUD when appropriate as part of tailored, youth-friendly services.

"People Don't Just Start Shooting Heroin on Their 18th Birthday": A Qualitative Study of Community Stakeholders' Perspectives on Adolescent Opioid Use and Opportunities for Intervention in Baltimore, Maryland

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders’ perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in opioid use prevention and treatment services in urban settings with longstanding opioid epidemics. In-depth interviews were conducted with 22 stakeholders representing health and social service agencies in Baltimore, Maryland from May 2018- February 2019, to examine their perspectives on the burden and context of adolescent opioid use and identify barriers and facilitators to preventing and responding to adolescent opioid use. Transcripts were analyzed using the constant comparison method to identify themes. Most respondents described a recent uptick in opioid use independently, and in combination with other substances. As compared to heroin, NMPO was perceived to be more frequently used and less stigmatized among youth. Stakeholders perceived the process of transitioning from using NMPO to heroin as more common among White vs. Black youth and was perceived as occurring faster among White vs. Black youth. Some stakeholders believed racial differences in internal stigma against heroin use, and differential health service use among Black youth and White youth may have influenced these differences. Trauma and poverty were noted determinants of youth opioid use. Barriers to service provision included youth cognitive development, stigma and structural factors (e.g., disinvestment, lack of youth-centered and integrated services). Stakeholders perceive prevalent NMPO among Baltimore youth and identify multilevel barriers to delivering prevention, treatment and harm reduction services to this population. These findings encourage further investigation of determinants and consequences of opioid use among diverse racial/ethnic groups of youth in urban settings, and development of multilevel, youth-driven and youth-centered approaches to prevention and treatment.

Current Prescription Opioid Misuse and Suicide Risk Behaviors Among High School Students

BACKGROUND AND OBJECTIVES

In previous studies, researchers have reported that youth with a lifetime history of prescription opioid misuse (POM) are at an increased risk for suicidal ideation, planning, and attempts. In this study, we investigate whether the association between youth POM and suicide outcomes differs by recency of POM (ie, none, past, or current misuse).

METHODS

In this report, we use data from the 2019 Youth Risk Behavior Survey to examine associations between recency of POM (current POM, past POM, and no POM) and suicide risk behaviors among US high school students.

RESULTS

After controlling for demographics, alcohol, and other drug use, both current POM and past POM were significantly associated with all suicide risk behaviors compared with no POM. Students who reported current POM had the highest adjusted prevalence ratios (aPRs) for suicidal ideation (aPR: 2.30; 95% confidence interval [CI] 1.97-2.69), planning (aPR: 2.33; 95% CI 1.99-2.79), attempts (aPR: 3.21; 95% CI 2.56-4.02), and feeling sad or hopeless (aPR: 1.59; 95% CI 1.37-1.84). Students who reported current POM also were significantly more likely than youth who reported past POM to report that they had seriously considered attempting suicide, made a suicide plan, and attempted suicide.

CONCLUSIONS

Although POM, particularly current POM, is associated with increases in the risk for suicide-related behaviors and experiences of youth, comprehensive prevention approaches that address the intersections between suicide and POM provide a promising path forward for addressing these public health challenges among youth.

Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery

BACKGROUND

Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain.

OBJECTIVES

As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures.

METHODS

We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure).

RESULTS

Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p < 0.01). There was significant variation in opioid prescribing patterns by provider (p < 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries.

CONCLUSIONS

Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.

Integrating substance use care into primary care for adolescents and young adults: Lessons learned

BACKGROUND

Substance use disorders are common chronic conditions that often begin and develop during adolescence and young adulthood, yet the delivery of primary care is not developmentally tailored for youth who use substances. Very few primary care-based substance use treatment programs exist in the United States for adolescents and young adults and no clear guidance is available about how to provide substance use treatment in primary care.

METHODS

We conducted a retrospective evaluation from July 2016 to December 2018 of a newly established primary care-based, multidisciplinary, outpatient program for youth who use substances. Components of the program include primary care, addiction treatment, harm reduction, naloxone distribution, psychotherapy, recovery support, and navigation addressing social determinants of health. We report the following patient characteristics and outcomes: demographics; proportion with substance use and mental health diagnoses; receipt of medications for opioid use disorder; retention in care at three, six, nine, and 12 months; and re-engagement in medical care.

RESULTS

From July 2016 through December 2018, 148 patients had at least one visit. Demographic characteristics included: median age 21 years; 40.5% female; 94.0% spoke primarily English; 18.3% Black, 14.9% Hispanic, and 60.8% white. One-third of patients (33.8%) were homeless or housing insecure. The most common substance use disorder was opioid use disorder (60.8%), followed by nicotine (37.2%), cannabis (20.9%), and alcohol (18.2%). Overall, 29.7% of patients had depression, 32.4% had anxiety disorder, and 18.9% had post-traumatic stress disorder. Retention in care was 29.7% at six months and 12.2% at 12 months. Among the 90 patients with OUD, 90.0% received medication for OUD, and 35.5% and 15.5% of patients with OUD were retained at six and 12 months, respectively. For patients lost to follow-up (no contact during a three-month period), the median time to re-engagement was 4.8 months, and 33.3% (37/111) of patients re-engaged. The most common reason for re-engagement was to access mental health treatment (59.5%) and primary care (51.4%).

CONCLUSIONS

Youth who sought care in a primary care-based substance use program presented most commonly with opioid, nicotine, cannabis, and alcohol use disorders. Co-morbid mental health diagnoses were common. While continuous retention at 12 months was low, one in three of the patients who fell out of care re-engaged. For youth receiving substance use care integrated into primary care, key components for pursing optimal retention in substance use treatment are a flexible model that anticipates the need for the treatment of mental health disorders and the use of re-engagement strategies.

Evaluating Opioid Dispensing Rates among Pediatrics and Young Adults based on CURES Data Reporting in California from 2015-2019

Background

Receipt of opioid prescriptions in pediatric and young adult patients may be a risk factor for future opioid misuse. Data from prescription drug monitoring programs provide insight on outpatient opioid use. In our study, we analyzed the opioid dispensing rates for pediatrics and young adults in California.

Methods

A secondary analysis was performed from 2015-2019 using Controlled Utilization Review and Evaluation System data. This database provides dispensing data of controlled substances in California. Patients younger than 25 years who were prescribed opiates were analyzed by county. We further divided them into two groups (children: ≤14 years; adolescents and young adult: 15-24 years). Descriptive statistics and heat maps were used to illustrate the trends in opioid usage among different age groups.

Results

The overall percentages for the number of opioids being dispensed to patients aged <25 years have decreased over the past four years. In 2015, 6 out of 58 counties in California were considered "high-rate" with >2.9% of opioids dispensed to patients younger than 25 years old; in 2019, this number reduced to zero. Patients 25 and older received a higher proportion of opioids compared to younger populations; in 2019, 35.91% of opioids were dispensed to patients 45-64, and 8.92% to patients younger than 25.

Conclusion

Pediatric opioid prescriptions have declined over the recent years. However, a high degree of variability of prescription rates between demographic counties was noted. More studies are warranted in order to understand this discrepancy in opioid prescribing among pediatric and young adult patients.

Trends in Dispensed Opioid Analgesic Prescriptions to Children in South Carolina: 2010-2017

BACKGROUND AND OBJECTIVES

Despite published declines in opioid prescribing and dispensing to children in the past decade, in few studies have researchers evaluated all children in 1 state or examined changes in mean daily opioid dispensed. In this study, we evaluated changes in the rate of dispensed opioid analgesics and the mean daily opioid dispensed to persons 0 to 18 years old in 1 state over an 8-year period.

METHODS

We identified opioid analgesics dispensed to children 0 to 18 years old between 2010 and 2017 using South Carolina prescription drug monitoring program data. We used generalized linear regression analyses to examine changes over time in the following: (1) rate of dispensed opioid prescriptions and (2) mean daily morphine milligram equivalents (MMEs) per prescription.

RESULTS

From the first quarter of 2010 to the end of the fourth quarter of 2017, the quarterly rate of opioids dispensed decreased from 18.68 prescriptions per 1000 state residents to 12.03 per 1000 residents (P < .0001). The largest declines were among the oldest individuals, such as the 41.2% decline among 18-year-olds. From 2010 through 2017, the mean daily MME dispensed declined by 7.6%, from 40.7 MMEs per day in 2010 to 37.6 MMEs per day in 2017 (P < .0001), but the decrease was limited to children 0 to 9 years old.

CONCLUSIONS

The rate of opioid analgesic prescriptions dispensed to children 0 to 18 years old in South Carolina declined by 35.6% over the years 2010-2017; however, the MME dispensed per day declined minimally, suggesting that more can be done to improve opioid prescribing and dispensing.

Effective Reduction in Opioid Prescriptions for Ambulatory Lesion Excisions in Pediatric Patients

Childhood opioid consumption is potentially deleterious to cognitive development and may predispose children to later addiction. Opioids are frequently prescribed for outpatient surgery but may not be necessary for adequate pain control. We aimed to reduce opioid prescriptions for outpatient pediatric skin and soft tissue lesion excisions using quality improvement (QI) methods.

METHODS

A multidisciplinary team identified drivers for opioid prescriptions. Interventions were provider education, improving computer order set defaults, and promoting non-narcotic pain control strategies and patient-family education. Outcomes included percentage of patients receiving opioid prescriptions and patient-satisfaction scores. Data were retrospectively collected for 3 years before the QI project and prospectively tracked over the 8-month QI period and the following 18 months.

RESULTS

The percentage of patients receiving an opioid prescription after outpatient skin or soft tissue excision dropped significantly from 18% before intervention to 6% at the end of the intervention period. Patient-reported satisfaction with pain control improved following the QI intervention. Satisfaction with postoperative pain control was independent of closure size or receipt of a postoperative opioid prescription. Intraoperative use of lidocaine or bupivacaine significantly decreased the incidence of postoperative opioid prescription in both bivariate and multivariate analyses. Results were maintained at 18 months after the conclusion of the QI project.

CONCLUSION

Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.