Pediatric Opioid Exposure Declining, but Problem Persists

Ricki Lewis, PhD

March 21, 2017

Cases of opioid poisoning among people younger than 20 years are declining in the United States, but the problem remains serious, according to two studies published online March 20 in Pediatrics.

Whereas previous studies have focused on patients treated in the emergency department and/or hospitalized, or only on fatalities, one of the new studies takes a broader view, looking at national statistics. Jakob D. Allen, from the Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital and the Central Ohio Poison Center, Columbus, Ohio, and colleagues analyzed information from the National Poison Data System to investigate the epidemiology of opioid exposure among the young.

The investigators found 188,468 exposures of young people to opioid drugs reported to poison control centers from all throughout the United States between 2000 and 2015. On average, 11,779 exposures are reported annually, or 14.34 exposures per 100,000 individuals younger than 20 years.

The authors considered reasons for opiate exposure, substance formulation, exposure site in the community, and age in years (0 - 5, 6 - 12, and 13 - 19 years).

The design distinguished more serious outcomes from less serious ones. Serious outcomes included death, major effect (symptoms that are life-threatening or cause significant disability or disfigurement), or moderate effect (symptoms that are more pronounced, prolonged, or systemic than minor symptoms and require treatment).

During the study period, poison control centers received a call approximately every 45 minutes, adding up to 32 calls a day, according to a related news release from Nationwide Children's Hospital.

Of the calls, 59.7% concerned children younger than 5 years, and 29.9% were about teenagers. The exposures were most likely to have occurred at a home (95.8%), and in most cases, the patient ingested the drug (98.4%). Adolescents were more likely to have intentionally used the drugs.

Both sexes were at risk. In the youngest age group, the sexes were about equally represented (53.2% boys), but boys accounted for 57.9% of exposures in the middle age bracket, and girls had more exposures (55.7%) among teenagers.

Adolescents were at greater risk of requiring admission to a healthcare facility than young children (odds ratio [OR], 2.86; 95% confidence interval [CI], 2.78 - 2.94) or children aged 6 to 12 years (OR, 6.52; 95% CI, 6.06 - 7.02). Teenagers also were more likely to experience serious medical outcomes than children aged 0 to 5 years (OR, 3.03; 95% CI, 2.92 - 3.15) or 6 to 12 years (OR, 4.59; 95% CI, 4.21 - 5.00). The suspected suicide rate attributable to opioid use among adolescents increased by 52.7% during the study period.

Hydrocodone was the most commonly used drug in all reported exposures (28.7%), followed by oxycodone (17.6%), and codeine (16.5%). Among children younger than 13 years, methadone and buprenorphine use led to more serious outcomes (including deaths) and hospital admissions than other opioids, despite the two drugs accounting for fewer exposures overall.

Settings and situations varied. Exposures to young children tended to occur at home, typically resulting from curiosity. In contrast, 71.5% of exposures among teenagers were intentional. "Seventy percent of teenagers who use prescription medications without a physician's order obtain the drugs from friends or relatives," the authors write.

Meanwhile, therapeutic errors accounted for 18.1% of all exposures, and 54.5% of exposures among children aged 6 to 12 years. These errors included taking someone else's medication, using the wrong drug, or incorrect dosing.

Limitations of the study include underestimation resulting from incomplete reporting, self-reporting, and no consideration of repeat exposures.

"Physicians can help reduce the availability of opioids by using correct dosing (not prescribing a higher dose or greater supply than necessary), reminding parents to safeguard prescription medications (including from teenagers), and encouraging prompt and proper disposal of unused medications," the researchers conclude. They suggest that a practical safety measure is to not package drugs loose in bottles, so that the number of pills taken is easier to track.

Prior Medical Exposure Often Precedes Nonmedical Opioid Use

In the second study, Sean Esteban McCabe, PhD, from the Institute for Research on Women and Gender and the Substance Abuse Research Center, University of Michigan, Ann Arbor, and colleagues investigated the connection between nonmedical opiate use among adolescents and prior therapeutic exposure to the drugs. Four studies have shown that a majority of adolescents who use opiates appropriately in a therapeutic situation do not report nonmedical use, but most adolescents who report nonmedical use have prior medical use of prescription opioids.

The researchers used data from the Monitoring the Future study to examine national trends in the medical and nonmedical use of prescription opioids among high school seniors between 1976 and 2015. Consistent with past reports, they found that a quarter of students reported using the drugs, and of those who did so nonmedically, most began with prescribed medication.

Sex differences emerged. The correlation was greater for males, who tended to get drugs from peers and use them to get high, whereas females were more likely to obtain drugs from relatives and use them for pain relief.

The good news is that medical and nonmedical uses of prescription opioids have declined, perhaps because of rising awareness of the addiction problem. Lifetime prevalence of medical use of opioids peaked in 1989 and 2002, remained stable, and then declined from 2013 through 2015.

Limitations of the study include self-reporting, not accounting for students absent on the day of the survey (who may have been more likely to have drug problems), and missing certain confounding variables, such as family history of substance use disorder.

One of Dr Allen's coauthors is reviewing a legal case involving buprenorphine. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online March 20, 2017. Allen full text, McCabe full text

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