1

Opioids and Pediatric Care:

Mapping the Minefield

Lisa B. Aiello RN, MSN, AOCNS, APRN-C

Dana C. Kemery EdD, MSN, RN, CNE, CEN, CPEN

2

Current State of Affairs

Number of Prescriptions

IMS Vector One. From “Prescription Drug Abuse: It’s Not what the doctor ordered.” Nora Volkow National Prescription

Drug Abuse Summit, April 2012. Available at http://www.slideshare.net/OPUNITE/nora-volkow-final-edits.

3

Current State of Affairs

MMEs per Prescription

MMEs/person

1997 96

2007 700 (↑600%) Every person in US

have hydrocodone

5mg q 4 hrs x 3

weeks

*CDC recommends concern for opioid doses ≥ 50 MME/day, or concurrent benzodiazepine use

*Avoid ≥ 90 MME/day Green, 2017

4

Current State of Affairs

Deaths

CDC, NCHS, National Vital Statistics System.

5

Adolescents

(12 to 17 years old) 2015

• 276,000 current nonmedical users of pain reliever • 122,000 addiction to prescription pain relievers • 21,000 adolescents who used heroin in the past year • 5,000 current heroin users • 6,000 adolescents had heroin use disorder in 2014 • The prescribing rates for prescription opioids among

adolescents and young adults nearly doubled from 1994 to 2007.

• Many are given prescription meds by a friend or family member.

ASAM (2016) Opioid Addiction 2016 Facts & Figures

6

More Statistics

• Alcohol use within a single month 9% of 8th graders 37.4% of 12th graders

• Illicit drugs within past year 27.2% of high school students

• Risk factors for age group Incomplete frontal lobe development affecting

judgment, impulse control, and feeling of invincibility • Nurse’s Role

Assess as a matter of course in all preteens and teens; provide education and referrals

7

https://www.cdc.gov/vitalsigns/heroin/infographic.html#graphic

8

Definitions

• Abuse o habitual use of substance outside

of medical necessity or social acceptance

o single purpose of altering one’s mood, emotion, or state of consciousness

• Addiction o chronic, relapsing brain disease

o characterized by compulsive drug-seeking

behavior motivated by craving, despite harmful consequences,

long-lasting changes to the brain

• Dependence o drugs can cause physical

dependence

o person relies on the drug to prevent symptoms of withdrawal.

• Tolerance o Over time, greater amounts of

the drug become necessary to produce the same effect.

9

TRANSITION TO

ADDICTION

• Taking drugs may begin as a voluntary

choice to seek a pleasant stimulus, but

for addicts, that choice is no longer

volitional, even in the face of terrible

personal consequences.

10

Minefields

• Parents/grandparents/guardians/families • Pediatric Use • Individual/peer groups • Environment • High risk prescription potential

Dental procedures Sports injuries Orthopedics Other surgeries

• Genetics

11

Pharmacogenomics

• CYP450 genes

• Metabolizing genes

• Exemplar

o Codeine/hydrocodon

e for pain and cough

medicines(<18)

o Tramadol (≤ 18)

o Nursing mothers

o Ultra rapid

metabolizers

o FDA – black box

warning

FDA, 2018

12

Adolescent Development

Adolescent brain Prefrontal cortex–

− controls cognitive function, such as memory, thinking, and learning

− still maturing in an adolescent brain − taking drugs at that time alters key

motivational circuits, forever changing the adult that kid was to become.

• Dopamine regulates pleasure and

pain and plays a major role in all addictions.

13

Risk Assessment:

Perform on ALL patients

H/O addiction in self H/O addiction in family H/O of mental illness H/O suicide H/O prescribed opiates (use/misuse) Social history Stress Recent trauma

14

Warning Signs of Heroin Use

Physical: • Small or pinpoint

pupils • Dramatic weight

changes • Frequent nose bleeds • Frequent colds or

illness • Itchy skin • Poor complexion • Pale or ashen

coloration • Sudden hair loss • Poor hygiene

Environmental:

• Cotton balls or Q-tips

• Cut cigarette filters

• Blood stains

• Lighters

• Missing alcohol

• Locked doors

• Pen parts, straws

• Burnt foil

• Missing prescriptions

• White or beige powder

• Burn marks on floors or carpet

Behavioral:

• Excessive lying

• Long sleeves in warm weather

• Anxious

• Change in personality

• Change in peer group

• Change in routine

• Altered sleep habits

• Loss of appetite

• Sudden isolation

• School performance

• Urgent need of money

• Nodding off

• Secrecy

http://www.letsfaceheroin.com/parents.html

15

16

Ohio police share shocking photos of adults who

OD'd with 4-year-old in back seat

- PUBLISHED: 09/09/16 10:17 AM EDT

17

Negative Consequences

• Isolation • Truancy • Stealing • Prostitution • Malnutrition • Complications r/t IVDA • Incarceration • Death

18

Other Drug Use in Adolescents

19

https://www.cdc.gov/vitalsigns/heroin/infographic.html#graphic

20

Reversal of Opioids/OD

• Naloxone (Narcan) - wears off in 20-90 minutes

• Naltrexone

• Nalmefene

21

NCSL, 2017

51 States have Naloxone Access Laws PDAPS,

2017

22

23

Clinical Picture of

Opioid Withdrawal

24

Pharmacologic Therapy

Opioid Addiction

• Naloxone (Narcan) – for OD o Disadvantage - short-acting

o Emergency use: same dose

for children

• Naltrexone (Revia) o Opioid antagonist

o Injectable version (Vivitrol)

o Children: Safety/efficacy not

established

• Methadone (Dolophine) o Slow-acting opioid agonist

o Synthetic opiate that blocks the

craving for and effects of heroin

o Detox tool

• Buprenorphine (Subutex) o Partial opioid agonist

o Not recommended < 16 years

• Buprenorphine and

naloxone (Suboxone) o <16 years

o Caution with pregnant women

neonatal withdrawal

neonatal demise

25

Treatment

Options

• Psychotherapy

• Treat underlying mental health illness

• Methadone

• Detox followed by inpatient rehab

• 12-Step programs

• Long term outpatient follow up

Reality of

Care

Decrease in adolescent

beds vs. increase in adult

beds

Limited anti-abuse

medications options

(methadone only)

Limited EBP

Limited Follow up and

nonadherence

12-step groups – many

groups are adult-focused

26

After stopping drug use,

relapse is often fatal.

27

Prescription Management

Prescription drugs are often the gateway to opiate addiction

Prescribe only the amount needed.

Keep medications locked up Properly dispose of unused

prescriptions. Visit the RX Drug Drop Box

Website http://www.rxdrugdropbox.org

28

Care Implications

• Perform risk

assessment on ALL

patients

• Monitor patients on

opioids

• Interdisciplinary care

• Educate patient/family

re

o Risks for misuse/abuse

o Proper prescription

management

o Warning signs

o Community resources

• Use mandatory Prescription Drug Monitoring Program (PDMP)

• Education regarding nasal naloxone

• Get involved

o Legislation

o Policy

o Advocacy

29

https://www.cdc.gov/vitalsigns/heroin/infographic.html#graphic

30

Thank you!!!

31

References

• Cerdá, M., Santaella, J., Marshall, B. D., Kim, J. H., & Martins, S. S. (2015). Nonmedical prescription opioid use in childhood and early adolescence predicts transitions to heroin use in young adulthood a national study. The Journal of Pediatrics, 167(3), 605-612. doi: 10.1016/j.jpeds.2015.04.071

• Costello, M., Thompson, S., Aurelien, J., & Luc, T. (2016). Patient opioid education research shows nurses’ knowledge of opioids makes a difference. Medsurg Nursing, 25(5), 307-311, 333. Retrieved from http://www.medsurgnursing.net/cgi-bin/WebObjects/MSNJournal.woa

• Ehrentraut, J. H., Kern, K. D., Long, S. A., An, A. Q., Faughnan, L. G., & Anghelescu, D. L. (2014). Opioid misuse behaviors in adolescents and young adults in a hematology oncology setting. Journal of Pediatric Psychology, 39(10), 1149-1160. doi: 10.1093/jpepsy/jsu072

• Federal Drug Administration. (2018). FDA drug safety communication. Retrieved at https://www.fda.gov/Drugs/DrugSafety/ucm590435.htm

• Hawthorne, J., Stein, P., Aulisio, M., Humphries, L., & Martin C. (2011). Opiate overdose in an adolescent after a dental procedure a case report. General Dentistry, 59(2), e46-e49. Retrieved from http://www.agd.org/publications-media/publications/general-dentistry.aspx

32

References

• London, M. L., Ladewig, P. A., Davidson, M. R., Ball, J. W., Bindler, R. C., & Cowen, K. J. (2014). Maternal & child nursing care (4th ed.). Upper Saddle River, NJ: Pearson.

• Miech, R., Johnston, L., O’Malley, P. M., Keyes, K. M., & Heard, K. (2015). Prescription opioids in adolescence and future opioid misuse. Pediatrics, 136(5), e1170-e1177. doi: 10.1542/peds.2015-1364

• National Conference of State Legislatures. (2017). Drug overdose immunity and good samaratin laws. Retrieved at http://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx

• Prescription Drug Abuse Policy System. (2017). Naloxone overdose prevention laws. Retrieved at http://pdaps.org/datasets/laws-regulating-administration-of-naloxone-1501695139

• Substance Abuse and Mental Health Services Administration. (2017). Reports by geography. Retrieved from https://www.samhsa.gov/data/reports-by-geography?tid=660&map=1

• Varcarolis, E. M. (2017). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (3rd ed.). St. Louis, MO: Elsevier.