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MIRIAM SCHIZER: Opioid use in adolescents. So the objectives for these 40 minutes, we’re goingto talk some about epidemiology, we’re going to talk about the neurobiology of opioids, and thenvery importantly, I’m going to highlight the appropriate use of medication to treat patients withopioid use disorder.
It’s very important to think about Narcan or naloxone for the reversal of opioid overdose. And thenI’d like to close with some uplifting thoughts about how parents and medical providers can actuallyprevent– ideally prevent opioid addiction from ever taking place.
I’m going to do a free promotion. Our program has been asked by the PPOC to give a series of two-hour trainings on how to prescribe buprenorphine. This has to do with upcoming changes to theMassHealth ACO that are going to take place in 2023. And so I’m actually giving the firstbuprenorphine training on Tuesday, October 25. And so we’re going to talk about buprenorphinetoday, but this next session will be a much deeper dive. So again, please pay attention today, and ifyou’re interested, you could attend one of these trainings and really become more of an expert inprescribing buprenorphine.
So just to set the stage, I like to say that you would have had to be living under a rock to be unawareof the extent of America’s opioid crisis. I always use the slide because I find it visually arresting. Thiswas the cover of a New York Times Sunday Magazine a few years ago. “Inside a Killer DrugEpidemic– A Look at America’s Opioid Crisis.”
So this is data from 2020 looking at the number of national drug-involved overdose deaths, and Ithink this picture tells its own story. You can see how the number of people dying each year hasincreased dramatically over the last few years. The next slide is similar, except it’s only showing youdeaths in which an opioid was the cause of death. And you can see, if you compare the numbers,this is about– this is a very significant percentage of all overdose deaths.
This breaks it down by agent. This is an important slide. You will see that, especially since about2014, 2015, the steepest rise in overdose deaths are attributed to synthetic opioids other thanmethadone. Whenever you see that phrase, that is referring to fentanyl.
So fentanyl has become the major factor driving this dramatic increase in overdose deaths. You’llsee that prescription opioids was also related, and then heroin, and we’re going to talk about that ina couple of minutes. We’re also following a significant increase in overdose deaths due topsychostimulants, which is methamphetamine, because cocaine is a separate category.
So it’s interesting to think of the history of the opioid crisis. What we saw initially was the first wavewas a rise in overdose deaths directly tied to prescription opioid use that’s in– I’m going to call thatteal. Then the second wave was a heroin overdose deaths. And then the third wave, which we’re inthe midst of right now, is fentanyl. And then this line in black just tells you overdose deaths due toany of these opioids.
So the pandemic made a bad situation worse. We know that there was an increase in overdosedeaths. We’ve seen the mental health crisis that resulted from the pandemic, and so this was noexception. You can see that from– in the 12 months prior to April 2021, we were thick in the middleof the pandemic at that point. There were 100,000 deaths. And if you went back five years ago,there was just about half that number of deaths. So the pandemic definitely made the situationworse.
We’re seeing an increase in overdose deaths in our population, in adolescents without a doubt. Andyou can see from 2019 to 2021, this is a very alarming increase, and this is fentanyl.
All right, so now we’re going to talk about some of the nuts and bolts of opioids and theirneurobiology. So it’s important to know the language. I would encourage you, whenever you arereferring to these compounds, to use the umbrella term, which is opioids. So if you catch yourselfusing opiate, then you want to use opioid instead.
Opiate actually has a very narrow definition. These are natural compounds that are derived from theopium poppy. There’s a milky sap that you can derive from opium which contains morphine andcodeine. Generally, opioids is the term that includes everything that binds to the mu opioidreceptors.
So this includes opiates, endogenous opioid– so those are your endorphins, your runner’s high as itused to be called. Opiates we’ve discussed. Semi-synthetic opioids is an important category thatincludes heroin, which is diacetylmorphine that’s derived from morphine, buprenorphine, andoxycodone. And then fully synthetic opioids really refers to two important drugs, fentanyl andmethadone.
So if you’re interested in trivia, there are actually three different types of opioid receptors in humans,but we’re going to be talking about the mu opioid receptor, which is responsible for all the clinicallysignificant effects in humans.
All right, so what do opioids do physiologically? When an opioid binds to a mu receptor in thecentral nervous system, you can get a number of different effects. Not surprisingly, analgesia, weknow that these are exploited for their potential as painkillers. Sedation.
Some patients will experience euphoria and that’s not universal. Pinpoint pupils is a well known sideeffect of opioid use. And then patients will develop a decrease in respiration and a decrease in heartrate. This is what is potentially lethal in overdose, particularly respiratory depression. Nausea is afrequent side effect of opioids.
We know that there are more receptors in the gut, which, when bound or when activated, candecrease motility and can cause constipation. That’s a common side effect.
So it’s important to recognize the symptoms and signs of opioid intoxication. So the classicsymptom is euphoria. We’ve also talked about analgesia. This is a classic downer, if you will. Sopatients are somnolent, they’re calm. Nodding off is a classic effect.
So the signs are, everything slows down. So heart rate, respiratory rate, patients breathe moreshallowly. I’ve mentioned the pinpoint pupils. Blood pressure decreases, temperature decreases.These patients are sedated. You might notice a slowed down movement, speech can be slurred,and again, nodding off is a classic sign of opioid use. I know I have a lot of patients in my practicewho parents will know that they relapsed when they start nodding off again.
It’s important to understand tolerance and withdrawal in the context of opioids. As we talked aboutin the first session, tolerance refers to the need for increasing amounts of the substance to achievethe desired effect. This also takes place with patients who are taking their opioid prescription asprescribed. You often need to increase the dose because of tolerance.
Withdrawal is a very important component of opioid use, which means that the patient has a certainset of symptoms if there is a rapid decline in receptor binding. And this can take place if there’s theopioid is not there. The patient is using fentanyl every day and then they run out. So there’s going tobe withdrawal. Or if you introduce a blocking agent such as naloxone or naltrexone, then you willhave physiologic withdrawal.
Patients develop tolerance to opioid effects and this is really important to understand as you thinkabout patients with opioid use disorder. What’s interesting is tolerance develops differentially todifferent effects. And so patients rapidly develop tolerance to sedation, euphoria, respiratorydepression, and nausea.
Surprisingly, they don’t develop tolerance to the constipation or the pupil constriction. And so this isreally important because if a patient is abstinent for a period of time– let’s say they are doing well,they’re not using, or they’re incarcerated, or they’re taking naltrexone and they’re not using, theylose their tolerance, and what frequently happens is if a patient has a slip, they use the dose thatthey were using previously.
They don’t factor in this loss of tolerance. And so this becomes a lethal dose. That’s a unfortunatelya common scenario for overdose deaths.
So it’s important to be familiar with the signs and symptoms of opioid withdrawal. Generally, opioidwithdrawal is not life-threatening like alcohol and benzodiazepines, which is potentially a life-threatening withdrawal syndrome, but it’s incredibly unpleasant and people– patients really dreadhaving these symptoms.
I would think of it as like a bad case of the flu or, these days, COVID. Typical symptoms are GI, youcan have cramping, nausea, vomiting, diarrhea. Patients have really bad muscle aches or boneaches. So think of the myalgia that you had the last time you had the flu. Generally, patients are veryanxious as well.
Signs, things that you can objectively measure would include increased blood pressure, increasedheart rate, increased body temperature. Generally when you think of a withdrawal state, I’ve saidthis before, it’s the opposite of the intoxication state. So this all makes sense.
Patients can have a runny nose, watery eyes, pathological yawning. You can see goose pimples– Ithink that’s what I call called it when I was a kid. It’s important to understand the timing ofwithdrawal symptoms.
For short-acting opioids, these symptoms can set in fairly rapidly, as soon as six hours after the lastuse. Patients can already start feeling withdrawal symptoms and this is often what drives thecompulsive use. Not so much the euphoria, which patients stop experiencing, but the desire toavoid feeling sick.
For long-acting opioids such as methadone, withdrawal symptoms are delayed. They start later andthen they end later. Shorter-acting opioids, generally after about five days you start feeling better.
So how did we get in this situation? It’s important to understand what happened in the era from,let’s say, 1990 to about 2015. There was a lot of attention paid to the importance of physiciansadequately prescribing and treating pain. This coincided with the advent of some very potentprescription opioids which were advertised as non-addictive. And so this led to a dramatic increasein opioid prescribing which you could see in this period in question.
And this, unfortunately, led to the creation of an opioid reservoir. An example would be a patient whowas prescribed Vicodin for oral surgery, was given 30 Vicodin, used one or two, and then put therest in a medicine cabinet. And so we know that this is where adolescents in many, many casesoften got their hands on opioids.
The good news is that there’s been a lot of attention paid to this phenomenon, and the medicalcommunity in general has gotten a lot better about not prescribing controlled substances, includingopioids, as aggressively.
So we’ve talked about monitoring the future before. This is looking at rates of opioid misuse by 12thgraders, you can see, between 1975 and 2000. I think close to where we are now. Sorry, that’s areally small number. And so you can see that this is the period in question when there was thisopioid reservoir, and so adolescents were misusing opioids at much higher rates, and thankfully,we’ve seen that number go down.
So adolescents were asked why they were misusing opioids. The answers were really consistentover this period of time. They were easy to get. Adolescents are opportunists to a large degree. Soyou could get them either in your family’s medicine cabinet or friends.
And I always want to point out that when patients are misusing prescription drugs, there’s always afalse perception of safety, that because this is a prescription drug, because a doctor wrote aprescription for it, it must be safer than a street drug. And we know, we looked at overdose deathsfrom prescription opioids, that is not necessarily the case. But this was the gestalt for rationale formisusing opioids.
It’s interesting. If you look at reasons that people give for what we call non-medical use of painrelievers, a lot of patients are, quote, “self-medicating.” They’re using this for what we callinstrumental reasons, which is they really think they’re doing this to help them, either by relievingpain, relieving tension, helping with their emotions, or helping with sleep.
But regardless of their intention– in other words, as opposed to recreational use or to try to gethigh, but all of these patients, regardless of why they’re using it, are at greater risk of going on tomisuse opioids and develop an opioid use disorder.
I want to say a few words about heroin and fentanyl. We’re not seeing a lot of heroin right now. Ihaven’t seen a patient actively using heroin in a few years now, but heroin is diacetylmorphine. Itrapidly crosses the blood-brain barrier. And we know that all of the drugs that are used for abuse aretypically fast-acting, that’s what people are looking for.
And so heroin, it used to be less potent, and so you would have to use it by injection, but over time,it’s gotten a lot more potent, and so patients– or individuals can also use it by smoking or bysnorting or by insulation. And this, unfortunately, lowered the barrier for a lot of people for usingheroin.
What was often the case, we were seeing patients who were using prescription opioids, theybecame too expensive, and so they transitioned to heroin, which is essentially the same effect, but itwas much cheaper.
Now there’s a new kid on the block, very lethal kid on the block, fentanyl, which is a syntheticopioid, which is 50 times more potent than heroin, 100 times more potent than morphine. It’s widelyavailable. It comes in either powder or pills. And this is, as we saw, this is what’s driving a lot of theuptick in overdose deaths.
So fentanyl is showing up in other substances. There was some press about overdose deaths inConnecticut from marijuana that was found to be laced with fentanyl. So this is really scary stuff. It’sabsolutely fair to share this with your patients.
The DEA is doing an important campaign. You can have this phrase in your head and tell patients,”One Pill Can Kill.” Very catchy phrase. And this refers to what I had also on a previous slide, whichis, fentanyl is often added to other substances because it’s relatively inexpensive and a very smallamount can produce a high.
So patients can think that they’re purchasing something else and they end up– they’re gettingfentanyl and the fentanyl can be lethal. So there are fake pills that are available. Your adolescentpatients can get access to these pills. Sometimes they’re rainbow-colored, which is particularlyalarming.
And it turns out that of the pills that are found to contain fentanyl, about 40% of them have apotentially lethal dose. So if you recall the slide that I showed you with a very dramatic increase inadolescent overdose deaths, this is a big contributor. So certainly have a very low threshold fortalking to your patients about Narcan or naloxone. I’m going to say a few words– a few more wordsin a couple of minutes.
So hopefully this is a familiar theme to this group that– it could be like a mantra for our learningsession, that the younger an adolescent is when they begin using a substance, the more likely theyare to have a fulminant disorder. And so this is also true for non-medical use of prescription drugs.So as always, you’re going to be even more worried about your younger patients.
As I’ve said to this audience before, you can really think about cannabis, alcohol, and nicotine as thegateway drugs. It’s uncommon for a patient to start their journey of abusing– of using substancesby using opioids. And so, in fact, this is data from a secondary analysis of– let’s see. About 1,400patients in the Youth Risk Behavior Survey who reported non-medical opioid use, and then theywere asked have you used cigarettes, e-cigarettes, alcohol, and marijuana?
Yes is blue, no is orange. And you can see that these patients had used other substances. And soagain, talking to your patients about all substance use remains a very important intervention.
This was a study that showed, of patients who misused opioids, there were really two categoriesthere. The category of patients who were using it to relieve pain, they’re, I guess you could say, self-medicating. And then the other category who are using it to get high.
And what this shows you is– I’m starting in the lower-right– patients who are prescribed an opioidhave a elevated odds ratio, so they’re about a third more likely to go on to misuse opioids. So evengiving someone illicit prescription for opioids puts them more at risk of misusing opioids. Patientswho are using opioids for pain relief but not as prescribed have a higher odds ratio. And then notsurprisingly, patients who try recreational use of opioids have a much higher odds ratio of going onto continue to misuse opioids.
This is just a reminder that should always be mindful of the mental health of your patient as riskfactors for more serious substance use disorder. We know that these are odds of developing asevere substance use disorder. All of these are risk factors.
So patients with depression, anxiety, familiar substance use– we’ve talked about genetic loading,and there are also environmental factors when a parent is using substances. And PTSD tends to beassociated with a particularly hard-to-treat form of substance use disorder.
All right, now we’re going to segue into treatment of patients with opioid use disorder. And then thisintroduces you to the two important categories, non-pharmacologic and pharmacologic. This is notan either/or scenario, this is a both. So when I talk about non-pharmacologic treatment, in our firstsession, we talked about levels of care.
A lot of these patients, when they present with opioid use disorder, would benefit from residentialtreatment, or at least an IOP or a partial hospital program, something more than seeing you and yourpractice. These patients have really, by definition, a severe substance use disorder. Individualcounseling is essential. Some patients will do well with group therapy, that adolescents tend to likethat because of the peer component.
Family therapy has very strong evidence base for adolescent substance use in general. And then alot of patients with opioid use disorder will do well in a cloistered environment in a recovery highschool or a therapeutic school.
Pharmacologic management is what we’re going to talk about now, and this starts with managingthe patient’s withdrawal symptoms. And then we’re going to talk about agonist therapy. I’m going toexplain what all this means, which is buprenorphine or methadone. And then antagonist therapy,which is your naltrexone.
All right, so I told you that patients who are withdrawing from opioids feel really sick. Think aboutbad flu or bad COVID. And so even patients who want to stop using, this is often the impediment.And so treating them for these symptoms with comfort medications can go a long way.
Clonidine works particularly well for the overarching restlessness and anxiety. That’s a locuscoeruleus type of symptom. Then the GI symptoms you can treat with an anti-diarrheal orondansetron. And then over-the-counter analgesics– the pain– the muscle aches tend to be veryprofound.
Or if a patient is willing to go to a facility, often they’re given a short course of methadone orbuprenorphine, which can be administered. They usually get a high dose and then a taper over afew days. And because this is a different opioid, it treats the withdrawal symptoms beautifully.
So medically supervised withdrawal, what we used to call detox, is really important because it canbe the first step in helping a patient consider treatment, but it’s important to know that this is notdefinitive treatment. The patient who was, quote, “in and out of detox,” end quote, but is still using.That’s because this is not definitive treatment. This is just really the step that gets them ready fordefinitive treatment.
All right, so now we’re going to talk about definitive treatment, which is the medications for opioiduse disorder. I would encourage all of you to read this. We can make this available to today’saudience. “Medication-Assisted Treatment of Adolescents With Opioid Use Disorders.” This was apolicy statement that was published in the American Academy of Pediatrics a few years ago. Ithappens to be beautifully written and really reads as a call to action.
Pediatricians should be comfortable prescribing these medications because they save lives, end ofstory. And if you’re not going to be a prescriber, then you should at least understand the importanceand refer your patients to someone who will prescribe.
I like to do a little aside about stigmatizing language. I think we’ve done a nice job in the field ofaddiction medicine of becoming much more aware of the language that we’re using and thepotential harm of that language. For an example, I would encourage you to lose the term “substanceabuse” from your language. We even changed the name of our program so that “substance abuse”was not in the title.
“Addict,” “substance abuser,” these are all very negative, pejorative terms. And so the preferredterm would be a person with a substance use disorder, person-first language.
The reason I put this here is that we used to use– “medication-assisted treatment” was the buzzphrase for these medications, but we’re now using medication for opioid use disorder– you’ll oftensee M-O-U-D– for this.
And the idea is that the medication is not a secondary treatment, it is an essential treatment. And Iwould encourage you to think that you wouldn’t call insulin medication-assisted treatment forpatients with diabetes, it’s the treatment. And so I want you to think about these medications in thesame way.
So now we’re going to talk about how these medications work. This is a brief overview. And again, Ireally want to put in a plug for the two-hour buprenorphine training that we’re going to be doing on aseries of different dates starting next Tuesday because that will give you a more comprehensiveunderstanding if you’d like to start prescribing.
So as you think about these medications, it’s important to understand that there are three categoriesfor opioid function and receptors. We’re going to talk about full agonists, partial agonists, andantagonists. And it’s important to remember that antagonists will have the highest affinity for thereceptor and full agonists will have the lowest. That will make sense in just a few minutes.
So if you look at my little schematics, when we talk about the full opioid agonists, this is yourmethadone, fentanyl, oxycodone, morphine, codeine. So these form, as you can see, a perfect lock-and-key fit with the mu opioid receptor. As such, these have the highest degree of opioid activity atthe receptor. So these are the most reinforcing and the greatest potential for development of a usedisorder.
Buprenorphine is a special category. This is a partial agonist which, as you can see by theschematic, does sit on the opioid receptor but has an imperfect fit. So this results in what I wouldcall gentle stimulation of the opioid receptor. You heard the patient in the clip say he’s not high whenhe takes Suboxone, but he just has this feeling of well-being. And we know that there’s lesspotential for misuse of buprenorphine because it’s not a full agonist, but the potential for misuse isnot zero.
So antagonists are the third category. These are blocking agents. So they sit on the receptors, suchas my wine cork, and they block the receptor, but they don’t stimulate it. So this includes naltrexone,which is used as a medication for opioid use disorder, and naloxone or Narcan.
And it’s important to understand that these compounds have the greatest affinity for the receptor.So if there’s something else on the receptor and you give an antagonist, it will displace the opioidresulting in withdrawal. And that’s how it treats an overdose.
I’m not going to say much about methadone. I don’t have any experience prescribing methadone.This is available at methadone clinics, but it’s important to understand that it’s out there. This doeswork as a full agonist at the opioid receptor. And patients do well in methadone. These are not youryounger adolescents, these are generally patients 18 and up.
And over the years, we’ve had a small number of patients who haven’t done well with buprenorphineand we’ve referred them to methadone and they’ve done well. Patients who generally need a lot ofstructure do well with methadone.
So buprenorphine was a game-changer when it came along. It was FDA-approved in 2002 for thetreatment of opioid use disorder and patients 16 and up. The beauty of buprenorphine is it can beprescribed. You don’t need a freestanding clinic, it can be prescribed from a physician’s office.
It is a controlled substance. It’s generally– when you talk about Suboxone, it’s a combinationproduct. It’s conjugated to naloxone, which limits the misuse potential. Generally, because it’s apartial agonist, it’s much safer. It’s very hard to overdose on buprenorphine. And it is mildlyreinforcing, which can support medication adherence.
When you think about side effects for buprenorphine, they’re similar to general side effects foropioids. Constipation is the biggie. If a patient had constipation when they were using an opioid,they’re probably going to have constipation with buprenorphine, but it’s usually not dose-limiting.
Patients often have nausea and fatigue in the beginning of treatment, but those effects wear off. Asmall percentage of patients will have neurologic symptoms, but that’s uncommon.
It is important to know about diversion potential for buprenorphine. If you’re prescribingbuprenorphine, there is a, quote, “street value” of this medication. And so we often have parentshold on to the medication and dispense it.
Usually people who are buying buprenorphine on the street are using opioids and they may want tohave buprenorphine for days when they don’t have an opioid and they’re feeling withdrawalsymptoms. So it’s important to do pill counts, and ideally a parent would hold the buprenorphineprescription.
So there used to be a requirement for an eight our course in order to get an X-waiver from the DEAto prescribe buprenorphine. I’m happy to say that in 2021, those restrictions were– or thoserequirements were liberalized. So if you’re going to be prescribing for fewer than 30 patients at atime, which most of us– I don’t treat 30 patients at one time, and then you don’t need a specifictraining, and so you could come to my two-hour training and then do the paperwork and be able toprescribe.
So we also have experience using naltrexone for the treatment of opioid use disorder. This works bya different mechanism. This is an antagonist. And so patients will take naltrexone. This will sit on theopioid receptor. And so if they use an opioid, there’s not going to be any effect.
Patients are aware of this, and so they’re less likely to use it. And there also is a measurabledecrease in cravings over time. This is also FDA-approved for the treatment of patients with alcoholuse disorder. So certainly if you have a patient that’s using alcohol and opioids, this becomes a no-brainer.
We know that the blockade lasts generally from one to three days. The dose for naltrexone is 50milligrams a day. What we like to do is we will have a patient take it orally, and then if they tolerate it,we’ll transition to Vivitrol, which is a trade name, which is a 30-day preparation of naltrexone thatyou can give them, see them once a month for an injection, and then they’re good for a month, theydon’t have to take a daily medication.
What’s tricky about naltrexone is– remember I told you that the antagonists have a greater affinity atthe opioid receptor. And so you need to wait a few days after the patient last used an opioid to makesure there’s none lingering because if you give them naltrexone and they recently used an opioid,the naltrexone will displace the opioid from the receptor and this will give what we call precipitatedwithdrawal.
The patient will have withdrawal squared. They’ll feel really sick and they’ll probably never comeback and see you again. So that’s the one tricky part for naltrexone.
There are some side effects, GI side effects, headache, dizziness. We usually try to work aroundthese side effects by starting on a lower dose and ramping up. And generally, this is a well-toleratedmedication. There are some case reports of hepatotoxicity, and so if you’re going to prescribenaltrexone, I would recommend that you always get a set of baseline LFTs before starting treatment.
All right. So in our last 10 minutes or so, we’re going to talk about evaluating a patient with an opioiduse disorder. You want to take a detailed history. It’s always important to know what is their opioidof choice, what are they using, how often, how are they using it? Are they taking it orally? Are they’resnorting or insulating? Are they injecting? Are they smoking? Are they using other substances at thesame time?
Patients with a history of a prior overdose have a dramatically increased risk for fatal overdose, sothat’s something you want to illicit in your history. Are parents aware of their use? And what is theirwillingness to engage in treatment? That’s a crucial question.
Any patient with a history of, I’m going to say, any pill use– One Pill Can Kill, you should make sureto prescribe Narcan or naloxone. If a patient is treatment-seeking or willing to engage in treatment,start high, do residential treatment, at least, or partial hospital program. These patients generallyneed very aggressive treatment at the outset.
For those patients that you’ve discovered they have an opioid use disorder and they’re saying “nothank you” to treatment, these are the patients that I would really encourage you to considerbreaking confidentiality. I know that might damage the therapeutic relationship, but if someone isusing fentanyl daily, this is a life-threatening condition.
So these are the patients that you’re really going to consider breaking confidentiality. If you do that,if you talk to the parents, and the patient, again, is resistant to treatment, parents might have to goto the court and file a Section 35, which is asking the court to hospitalize their child involuntarily, andusually that’s about a 30-day hospitalization.
So as we follow patients with opioid use disorder, urine drug testing is important. This is a greaturine drug test result for a patient who’s undergoing treatment. You’re seeing that the buprenorphineand the norbuprenorphine is in their urine, as you would hope it would be, but there’s nothing else.
This is actually the same urine drug test that we looked at before. This is a patient who’s not doingwell in treatment and needs– probably needs to be sectioned.
I’d like to say a few words about opioid overdose and the importance of Narcan or naloxone. Thereare different risk factors as you think about where does this patient fall in terms of risk? I would saythe most important risk factor is what opioid they’re using. When we know that a patient is usingfentanyl, that alone is a profound risk factor for opioid overdose.
Generally, we worry more about patients who are doing polydrug use or polypharmacy, particularlythe combination of alcohol, benzodiazepines, and/or opioids can be– you can have an overdosewith lower amounts because of the synergy and the respiratory depression.
Certainly we worry about patients who are using alone, patients who have medical problems. And asI mentioned earlier in the talk, patients who’ve had a period of abstinence are particularly high-riskbecause they’ve lost their tolerance, they go back to the dose they were using, and then thatbecomes a lethal dose.
Another category which is important to keep in mind is there’s a real last hurrah phenomenon thatI’ve seen unfortunately in our own practice, which is a patient is about to go to residential treatment,and so they have this last hurrah, and that can be life-threatening as well.
So here’s my schematic for Narcan. We talked about how opioid antagonists have a greater affinityat the opioid receptor. So naloxone, you give them naloxone and it will push the opioid off thereceptor. The patient will have precipitated withdrawal and wake up and start breathing again.
Generally, this is available as an intranasal and an auto injector. It works in one to three minutes.Just like if a patient used an EpiPen, you would say they should go to an ED. Very similar withNarcan because the Narcan will wear off, and potentially if they use a longer-acting opioid, theycould have another overdose after the naloxone wears off. So all of these patients should bemonitored in an ED.
If you think a patient may have overdose but you’re not sure, there’s really no downside to givingNarcan. If it’s not an opioid overdose, it just won’t have an effect.
All right, so in our last couple of minutes, we’re going to talk about prevention. So ideally, how wouldyou prevent patients from ever misusing an opioid or developing an opioid use disorder? And I’vealways loved being a pediatrician with the task of anticipatory guidance.
And so important take-home points are that we know that typically alcohol and cannabis use– Ishould add nicotine use– will proceed opioid use. It’s very unusual for patients to start by misusingan opioids. And so talking to parents about that as a risk factor for misusing opioids and, again, nottaking this type of substance use lightly is an important intervention.
Parents can set a good example. It’s really important that families not share their prescriptions. Itsends teens the wrong message. I’m not going to use someone else’s prescription, only use whatyou’re prescribed by a physician. It really does make a difference to talk to teens about drug use,including pills. One Pill Can Kill.
Parents should take alcohol and cannabis use seriously. And I showed you the picture of the opioidreservoir. Families– this is something that you should include in routine anticipatory guidance, thatfamilies should not store leftover medication because they can be an invitation to an adolescent at alater date.
I think there just was a take-back date. I think it’s in April and October, but every community has away in between these take-back days for families to get rid of prescription medication.
So my last thoughts are about what primary care clinicians can do to minimize the harm of opioiduse in adolescents. Hopefully as you’re sitting through this talk, you’re thinking that you’re going toset the bar really, really high forever prescribing an opioid.
If you have a patient with some sort of an acute pain problem, I would encourage you to bend overbackwards to use non-opioid analgesics, rely on the good old fashioned stuff like physical therapy,ice, everything else that is in your toolbox for treating patients with pain other than using opioids.
The picture on the lower-right is to remind me that patients with mental health disorders areparticularly tricky, their pain can be harder to treat, but they’re also, as we discussed earlier, moresusceptible to developing substance use disorders. So you want to be particularly careful withpatients with diagnoses of anxiety and depression.
Certainly we talked about the importance of screening. The STBI is your friend. So if you’re thinkingabout prescribing an opioid, you want to screen the patients. If they have a history of substance use,they are more high-risk, and again, you want to do everything you can to avoid opioid-prescribing.
If you feel like you don’t have a choice, then I would recommend that the parent be involved, theparent hold the prescription, dispense the medication, and then dispose of it as soon as the pain ismore manageable.
I think we do a nice job at Boston Children’s talking to families about the voluntary, non-opioiddirective. This is available at Boston Children’s Hospital. It really is just more of an educational pointthat if a family agrees, what this means is if a patient signs this form– or if you’re under 18, theparent signs the form, then you are saying that if I end up in your hospital emergency department,please don’t give me an opioid, please use other alternatives.
This is voluntary. Patients can rescind it when they present. So it’s really more of a teaching point.It’s really more of a formality. But I think finding a way in your practice to talk to families,adolescents, and their parents about avoiding opioid prescriptions, if at all possible, is aconversation that is really worth having.
So in conclusion, we know that opioid use among adolescents and young adults is a seriousproblem. I haven’t been subtle about listing the life-threatening consequences of this.
And you guys can do a lot, starting with screening your patients for opioid use, using caution andprescribing opioids, talking to your patients about prescription drug misuse, and then beingchampions for patients to be prescribed medication if they have developed a severe opioid usedisorder. You can prescribe buprenorphine yourself. Please come see me at one of these trainings.And certainly have a very low bar for prescribing Narcan to families with any high-risk features.