Opioid Epidemic Continues to Wreak Havoc in the Lives of Young Children

Michael Vlessides

April 02, 2020

Children younger than 6 years are exposed to fewer prescription narcotics now than they were in 2010, but the opioid epidemic continues to wreak havoc in the lives of society's most vulnerable citizens, new research shows.

An analysis of nearly 50,000 cases involving very young children concluded that exposure to opioids among the study population decreased significantly from 2010 through 2018, both per child and per prescription. The analysis also showed that many of the 28 deaths that occurred were preventable.

"Overall, it seems there is some slowing in pediatric opioid exposures when you control for population and opioid prescriptions dispensed, which is promising news," lead author G. Sam Wang, MD, told Medscape Medical News. "We also found that hydrocodone was the most commonly involved opioid, which is probably one of the most common oral opioids in the home.

"But methadone and buprenorphine actually had the highest exposure rates when you account for dispensed prescription, and methadone actually accounted for the most deaths in the population as well," added Wang, a medical toxicologist at Children's Hospital Colorado, in Denver.

The study was published online March 13 in Drug and Alcohol Dependence.

Serious Injury, ED Visits, Hospitalization

The effects of the prescription opioid epidemic in adults and adolescents has been well documented, but that epidemic "has not spared the pediatric population," the investigators note.

Between 2000 and 2009, children and adolescents experienced significantly increased opioid exposures, resulting in concomitant increases in serious injuries, emergency department (ED) visits, and hospitalizations relative to other prescription medications.

Previous studies failed to examine exposure rates attributable to dispensed opioid prescriptions and offer limited insight into root causes of death in children.

"There seems to be some curb in overall opioid exposures over the past couple of years, probably due to a combination of various factors," said Wang. "And so we wanted to know how we're doing in the pediatric world."

To examine trends, characteristics, and mortality among young pediatric patients with opioid exposures, the researchers used data from the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System, which collects product- and geographic-specific data from seven programs that evaluate different aspects of the drug-dependence pathway.

The investigators analyzed information from the RADARS Poison Center Program, which includes data on rates and outcomes associated with prescription opioid exposures in persons in the general population who contact participating poison centers. The analysis included data from July 1, 2010, to December 31, 2018.

Specifically, the researchers examined opioid exposure cases involving children younger than 6 years who were exposed to at least one of the following opioids: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, and tramadol. Each case was assigned a medical outcome using standard definitions for minor, moderate, and major effects.

Severe Consequences

The analysis identified 48,560 pediatric poison center cases during the analysis period. The median age of the patients was 2 years; 52.4% were boys.

The overall opioid analgesic pediatric exposure rate for the study period was 6.27 exposures per 100,000 children. The exposure rate decreased by 50% from a rate of 8.4 exposures/100,000 children in July 2010 to 4.2 exposures/100,000 children in December 2018.

"We like to think that perhaps improved and responsible use of opioids has led to improved counseling and a decrease in overall opioid prescriptions, which translate to less opioids in the home, and when things are less available in the home, they're less available to kids," said Wang.

After adjusting for drug availability using prescriptions dispensed, the researchers also found that both hydromorphone and fentanyl had increased exposure rates. On the other hand, buprenorphine had the greatest decrease in exposure rate per prescription dispensed.

The overwhelming majority of exposures (91.5%) were unintentional ingestions and occurred in the home environment (98.2%). There were also 102 reported cases of intentional misuse, abuse, or malicious use by a caregiver to a child. The most common opioid analgesics involved in nonfatal exposures were hydrocodone (32.5%), oxycodone (22.3%) and tramadol (20.8%).

Results also showed that 17% of children were admitted to a healthcare facility, including 8.5% to a critical care unit. The researchers found that 8% of the opioid exposures had moderate or major effects, including 28 deaths.

Children who suffered fatalities ranged in age from infancy to 5 years (median age, 2 years); 53.6% were girls. Methadone (16 patients; 57.1%) represented the majority of the deaths, followed by buprenorphine and oxycodone (five patients each; 17.9%). Two of the deaths involved suspected polypharmacy; the remainder were from single-opioid exposures.

Twenty-five of the recorded deaths occurred in the home or caregiver environment, including eight cases in which the child died under the supervision of someone other than a parent.

Two children who died of opioid overdose ― one from buprenorphine and one from methadone ― were first evaluated in an ED and were sent home after a brief observation period. Two other deaths occurred after children were intentionally given methadone to treat agitation.

Room for Improvement

"I think methadone and buprenorphine have come a long way to help people with addiction, but this study also demonstrates that there is a danger of having those in the home. We probably need to do an even better job of prevention in the homes where methadone and buprenorphine are available," said Wang.

Although the researchers were encouraged by the declining rates of opioid exposures in young children, they point out that these adverse outcomes are largely preventable.

Almost 90% of the exposures and three quarters of deaths were unintentional, and more than 70% of opioid exposures occurred in the home. As such, the authors recommend that healthcare practitioners continue to counsel their patients regarding the safe storage of opioids. With this in mind, programs such as Up & Away offer tips and tricks for proper medication storage in the home.

The researchers also note that modifying drug formulations and implementing engineering controls may also help address the problem.

One study showed that pill and tablet formulations were the most common in pediatric opioid exposures and that children were up to 8.8 times more likely to ingest tablets than they were single-wrapped film strips. Engineering interventions such as packaging modifications and flow restrictors for liquid formulations may also cut exposure risk.

The investigators note that it is critical to educate parents and other caregivers ― typically at the time of prescribing or purchase ― about the potential risks that opioids play in the lives of young children.

"We've come a long way, and we're getting to a better place, but we're still not there. We should consider engineering controls like flow restrictors on liquid medications and unit-dose packaging for some of the more common opioids we prescribe. Finally, I think special attention needs to be paid by clinics and providers who prescribe these medications to make sure that counseling is there as well," said Wang.

Commenting on the findings for Medscape Medical News, Gary A. Smith, MD, DrPH, director of the Center for Injury Research and Policy at Nationwide Children's Hospital, Columbus, Ohio, who was not involved in the study, said that exposures to opioid analgesics among children younger than 6 years can be life threatening and are preventable.

"The high number of exposed children reported in this study is not surprising given the ongoing opioid crisis in the US," said Smith, whose own research shows that children younger than 5 accounted for almost 90% of buprenorphine exposures between 2000 and 2015. "Unit-dose packaging and flow restrictors are proven but underutilized strategies that could decrease pediatric exposures and save lives," he said.

Wang and Smith have disclosed no relevant financial relationships.

Drug Alcohol Depend. Published online March 13, 2020. Abstract

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