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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
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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.
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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
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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
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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
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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
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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.