Marcia Frellick

September 17, 2017

CHICAGO — More children and young adults entering US emergency departments are dependent on opioids, new research suggests.

Using data from the Nationwide Emergency Department Sample, the largest all-payer emergency department (ED) database in the United States, investigators looked at patients who entered the ED for any reason and selected all patients up to 21 years old who had opioid dependence and abuse codes, and found 257,165 such visits.

Dependency numbers included prescription painkillers as well as illicit drugs such as heroin. The yearly numbers rose 54%, going from 32,235 in 2008 to 49,626 in 2013.

Veerajalandhar Allareddy, MD, MBA, medical director of the pediatric intensive care unit at the University of Iowa Stead Family Children's Hospital in Iowa City, said the numbers help define the problem as "an emerging public health crisis."

He told Medscape Medical News that "in pediatrics, we didn't expect these kinds of numbers."

The abstract will be presented September 18 here at the American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition.

Emerging Public Health Crisis

According to the findings, 88.3% of ED visits were made by those aged 18 to 21 years and 8.4% were made by teens aged 16 to 17 years.

Dr Allareddy points out these are just the young people who enter the health system through the ED. They do not account for those who enter through a different route.

"This is probably just skimming the top," he said. These numbers may also underreport the problem because these are the children whose providers thought to screen for opioid use. But many more have gone undetected, he pointed out.

"Kids are unlikely to tell you they have an opioid problem," he said, adding that there should be more testing in EDs. Basic questions should be asked of all children and adolescents entering the ED, and if there's a concern, they should get tested, he said, adding that the questions should also be addressed in primary care visits.

The researchers also found household income was predictive of hospital admission.

"Clearly those who come from high-income households were getting hospitalized, but those without insurance are unlikely to be admitted. Why we're getting that signal is unclear," he said.

This is an exploratory study, he added, and the reasons for the income discrepancies are among the questions that need further study.

Adverse Effects From Hospital Opioids Increase

In another abstract, presented at the conference September 15, researchers found that the number of infants, children, and adolescents who experience adverse effects from opioids in the hospital has increased by 56% between 2003 and 2012.

Jessica Barreto, MD, a third-year pediatrics resident at Nicklaus Children's Hospital in Miami, Florida, and colleagues looked at data from 2003, 2006, 2009, and 2012 from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Kids' Inpatient Database to study hospital stays for children aged 1 month to 17 years. They excluded newborns.

They found that opioid-related problems were documented in 16.6 children per 10,000 discharges. Prevalence increased steadily from 13.3 incidences per 10,000 discharges in 2003 to 20.8 per 10,000 discharges in 2012.

Some of the most common complications associated with opioids were withdrawal (3.1%; odds ratio [OR], 30.3; 95% confidence interval [CI], 25.2 - 36.4), constipation (12.5%; OR, 22.5; 95% CI, 20.5-24.8), urinary retention (2.3%; OR, 16.0; 95% CI, 13.0 - 19.8), and altered mental status (10.5%; OR, 8.3; 95% CI, 7.5 - 9.2).

Sharon Levy, MD, MPH, director of the Adolescent Substance Abuse Program for Boston Children's Hospital and associate professor of pediatrics at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News that she was struck by the larger increase in adverse effects in adolescents than in the youngest patients. If the reason for the increase was just more awareness around opioids' effects, she said, you would expect the increases to be more consistent across ages.

However, the adverse events were lowest in infants (20.1 per 10,000) and highest in the adolescent group (30.2 per 10,000; P < .01 for trend analysis).

"One would wonder looking at that is whether older kids, who are really going to be able to report their pain more, are just getting more opioids these days because of the trend to treat pain more aggressively," she said.

The study points out that the withdrawal rate in this population more than doubled from 2003, when it was 1.3% (OR, 29.1; 95% CI, 20.9 - 40.5).

"Withdrawal is a really good marker of exposure," she said. "You have to have opioids at a reasonable dose for a reasonable period of time before you're going to get withdrawal."

However, she cautioned against making assumptions about cause when this abstract makes only a correlation.

Gary Walco, PhD, director of pain medicine at Seattle Children's Hospital in Washington, also notes that the abstract has not been peer reviewed and adds that he would caution against reading too much into the correlation with adverse effects, particularly cardiac arrest.

He pointed out that the study shows a correlation of 1% between opioid use and cardiac arrest (1.0%; OR, 4.4; 95% CI, 3.2-6.1).

He told Medscape Medical News that percentage is "unfathomable."

"If 1 of 100 kids goes into cardiac arrest from getting an opioid, I can pretty much guarantee you those drugs would be pulled off the market," he said.

Dr Barreto said she agrees the number is high, and told Medscape Medical News that was a limitation of the database.

"When you analyze that type of information, you can only see if two diagnoses are associated," she said. "You know only that a person had a diagnostic code for cardiac arrest and also had a code for opioid adverse effects. It's a stepping stone study to see if there is an association."

Dr Walco says the study does not address an important issue: "What are the benefits of opioids, and what would the patients have experienced if they didn't have the pain adequately treated?"

He notes that there are two critical issues in looking at the opioid crisis: How do we curb misuse, and how do we effectively treat pain in children?

"The $50 million question is, How much do those issues overlap?" he said. "If you appropriately treat children's pain, how much are you adding to the opioid problem in this country? Especially if you're talking about treating pain on an inpatient basis, where you have 100% control over what's administered, the data so far would argue that those issues are fairly minimal."

Dr Barreto, Dr Levy, Dr Allareddy, and Dr Walco have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition. Abstracts presented September 15-18, 2017.

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