Opioid therapy in children and adolescents: A physician's guide to risk assessment, monitoring, and mitigation of abuse

Authors

  • Jessica Anne George, MD
  • Sabine Kost-Byerly, MD
  • Constance L. Monitto, MD

DOI:

https://doi.org/10.5055/jom.2013.0178

Keywords:

adolescents, diversion, pain management, opioid abuse, opioid misuse, drug screening, monitoring, risk assessment

Abstract

After conducting a thorough literature search of adolescent opioid use from 1990 until present, it became readily apparent that the last decade has witnessed an increase in the number of opioid-related drug overdoses and deaths in the adolescent population, analogous to the epidemic in the adult population. Most of these cases have resulted from prescription medication misuse. Practitioners who use controlled substances to treat pain in pediatric and adolescent patients want to limit harm by carefully assessing their patients’ risk of abuse and diversion. In this article, the authors present current knowledge and recommendations for the mitigation of aberrant prescription drug use in the pediatric population.

Author Biographies

Jessica Anne George, MD

Assistant Professor, Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institution, Baltimore, Maryland

Sabine Kost-Byerly, MD

Associate Professor, Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institution, Baltimore, Maryland

Constance L. Monitto, MD

Assistant Professor, Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institution, Baltimore, Maryland

References

Miotto K, Kaufman A, Kong A, et al.: Managing co-occurring substance use and pain disorders. Psychiatr Clin North Am. 2012; 35(2): 393-409.

Ghandour RM, Overpeck MD, Huang ZJ, et al.: Headache, stomachache, backache, and morning fatigue among adolescent girls in the united states: Associations with behavioral, sociodemographic, and environmental factors. Arch Pediatr Adolesc Med. 2004; 158(8): 797-803.

Fortuna R, Robbins B, Caiola E, et al.: Prescribing of controlled medications to adolescents and young adults in the united states. Pediatrics. 2010; 126(6): 1108-1116.

Richardson L, Fan M, McCarty C, et al.: Trends in the prescription of opioids for adolescents with non-cancer pain. Gen Hosp Psychiatry. 2011; 33(5): 423-428.

Roth-Isigkeit A, Thysen U, Stoven H, et al.: Pain among children and adolescents: Restrictions in daily living and triggering factors. Pediatrics. 2005; 115: E152-E162.

Phillips DM: JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA. 2000; 284(4): 428-429.

Atluri S, Akbik H, Sudarshan G: Prevention of opioid abuse in chronic non-cancer pain: An algorithmic, evidence based approach. Pain Physician. 2012; 15(3 Suppl): ES177-ES189.

Sehgal N, Manchikanti L, Smith HS: Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 2012; 15(3 Suppl): ES67-ES92.

Christo PJ, Manchikanti L, Ruan X, et al.: Urine drug testing in chronic pain. Pain Physician. 2011; 14(2): 123-143.

Manchikanti L, Fellows B, Ailinani H, et al.: Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. Pain Physician. 2010; 13(5): 401-435.

Sullivan MD, Edlund MJ, Fan MY, et al.: Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and Medicaid insurance plans: The TROUP study. Pain. 2010; 150(2): 332-339.

Trescot AM, Helm S, Hansen H, et al.: Opioids in the management of chronic non-cancer pain: An update of American Society of the Interventional Pain Physicians’ (ASIPP) guidelines. Pain Physician. 2008; 11(2 Suppl): S5-S62.

Edlund MJ, Martin BC, Fan MY, et al.: Risks for opioid abuse and dependence among recipients of chronic opioid therapy: Results from the TROUP study. Drug Alcohol Depend. 2010; 112(1-2): 90-98.

Noble M, Treadwell JR, Tregear SJ, et al.: Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010; (1): CD006605.

Wisniewski A, Purdy C, Blondell R: The epidemiologic association between opioid prescribing, non-medical use, and emergency department visits. J Addict Dis. 2008; 27(1): 1-11.

Committee on Substance Abuse, Levy SJ, Kokotailo PK: Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011; 128(5): e1330-e1340.

Hingson RW, Zha W: Age of drinking onset, alcohol use disorders, frequent heavy drinking, and unintentionally injuring oneself and others after drinking. Pediatrics. 2009; 123(6): 1477-1484.

Chambers RA, Taylor JR, Potenza MN: Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability. Am J Psychiatry. 2003; 160(6): 1041-1052.

Tims FM, Dennis ML, Hamilton N, et al.: Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Addiction. 2002; 97(Suppl 1): 46-57.

Johnston L, O’Malley P, Bachman J, et al.: Monitoring the Future: National Results on Adolescent Drug Use: Overview of Key Findings. Bethesda, MD: National Institute on Drug Abuse, 2005.

Friedman RA: The changing face of teenage drug abuse–The trend toward prescription drugs. N Engl J Med. 2006; 354(14): 1448-1450.

Tormoehlen LM, Mowry JB, Bodle JD, et al.: Increased adolescent opioid use and complications reported to a poison control center following the 2000 JCAHO pain initiative. Clin Toxicol (Phila). 2011; 49(6): 492-498.

McCabe SE, West BT, Teter CJ, et al.: Characteristics associated with the diversion of controlled medications among adolescents. Drug Alcohol Depend. 2011; 118(2-3): 452-458.

DuRant RH, Smith JA, Kreiter SR, et al.: The relationship between early age of onset of initial substance use and engaging in multiple health risk behaviors among young adolescents. Arch Pediatr Adolesc Med. 1999; 153(3): 286-291.

Steiner D: The Conundrum of Pediatric Research: Advances in Therapeutics and Technology Newsletter. Elk Grove Village, IL: American Academy of Pediatrics, 2012.

Pesce A, West C, Egan City K, et al.: Interpretation of urine drug testing in pain patients. Pain Med. 2012; 13(7): 868-885.

Slater ME, De Lima J, Campbell K, et al.: Opioids for the management of severe chronic nonmalignant pain in children: A retrospective 1-year practice survey in a children’s hospital. Pain Med. 2010; 11(2): 207-214.

Lee BH, Scharff L, Sethna NF, et al.: Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes. J Pediatr. 2002; 141(1): 135-140.

Sherry DD, Wallace CA, Kelley C, et al.: Short- and long-term outcomes of children with complex regional pain syndrome type I treated with exercise therapy. Clin J Pain. 1999; 15(3): 218-223.

Maynard CS, Amari A, Wieczorek B, et al.: Interdisciplinary behavioral rehabilitation of pediatric pain-associated disability: Retrospective review of an inpatient treatment protocol. J Pediatr Psychol. 2010; 35(2): 128-137.

Hechler T, Dobe M, Kosfelder J, et al.: Effectiveness of a 3 week multimodal inpatient pain treatment for adolescents suffering from chronic pain: Statistical and clinical significance. Clin J Pain. 2009; 25: 156-166.

Meighen KG: Duloxetine treatment of pediatric chronic pain and co-morbid major depressive disorder. J Child Adolesc Psychopharmacol. 2007; 17(1): 121-127.

Kaminski A, Kamper A, Thaler K, et al.: Antidepressants for the treatment of abdominal pain-related functional gastrointestinal disorders in children and adolescents. Cochrane Database Syst Rev. 2011; (7): CD008013.

Kimura Y, Walco GA: Treatment of chronic pain in pediatric rheumatic disease. Nat Clin Pract Rheumatol. 2007; 3(4): 210-218.

Manchikanti L, Benyamin R, Datta S, et al.: Opioids in chronic noncancer pain. Expert Rev Neurother. 2010; 10(5): 775-789.

Model Policy for the Use of Controlled Substances for the Treatment of Pain. Euless, TX: The Federation of State Medical Boards of the United States, Inc., 2004.

Gourlay DL, Heit HA, Almahrezi A: Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005; 6(2): 107-112.

Manchikanti L, Malla Y, Wargo B, et al.: Comparison evaluation of the accuracy of immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing (UDT) opioids and illicit drugs in chronic pain patients. Pain Physician. 2011; 14(2): 175-187.

Passik S, Kirsh K, Casper D: Addiction-related assessment tools and pain management: Instruments for screening, treatment planning, and monitoring compliance. Pain Med. 2008; 9(S2): S145-S166.

Substance Abuse and Mental Health Services Administration: The Relationship between Mental Health and Substance Abuse among Adolescents. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, 1999.

Knight JR, Shrier LA, Bravender TD, et al.: A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med. 1999; 153(6): 591-596.

Knight JR, Sherritt L, Shrier LA, et al.: Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002; 156(6): 607-614.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association, 2000.

Kulig JW, American Academy of Pediatrics Committee on Substance Abuse: Tobacco, alcohol, and other drugs: The role of the pediatrician in prevention, identification, and management of substance abuse. Pediatrics. 2005; 115(3): 816-821.

Manchikanti L, Abdi S, Atluri S, et al.: American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I–Evidence assessment. Pain Physician. 2012; 15(3 Suppl): S1-S65.

Manchikanti L, Abdi S, Atluri S, et al.: American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–Guidance. Pain Physician. 2012; 15(3 Suppl): S67-S116.

Manchikanti L, Ailinani H, Koyyalagunta D, et al.: A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain Physician. 2011; 14(2): 91-121.

Manchikanti L, Datta S, Smith HS, et al.: Evidence-based medicine, systematic reviews, and guidelines in interventional pain management: Part 6. Systematic reviews and meta-analyses of observational studies. Pain Physician. 2009; 12(5): 819-850.

Ballantyne JC: Opioid analgesia: Perspectives on right use and utility. Pain Physician. 2007; 10(3): 479-491.

Richardson LP, Russo JE, Katon W, et al.: Mental health disorders and long-term opioid use among adolescents and young adults with chronic pain. J Adolesc Health. 2012; 50(6): 553-558.

Vogel M, Dursteler-Macfarland KM, Walter M, et al.: Prolonged use of benzodiazepines is associated with childhood trauma in opioid-maintained patients. Drug Alcohol Depend. 2011; 119(1-2): 93-98.

Schanberg L, Anthony K, Lefebvre J, et al.: Family pain history predicts child health status in children with chronic rheumatic disease. Pediatrics. 2001; 108(3): E47.

Manchikanti L, Whitfield E, Pallone F: Evolution of the National All Schedules Prescription Electronic Reporting Act (NASPER): A public law for balancing treatment of pain and drug abuse and diversion. Pain Physician. 2005; 8(4): 335-347.

Wang J, Christo PJ: The influence of prescription monitoring programs on chronic pain management. Pain Physician. 2009; 12(3): 507-515.

Office of National Drug Control Policy: Epidemic: Responding to America’s prescription drug crisis. 2011. Available at http://www.whitehouse.gov/sites/default/files/ondcp/policyand-research/rx_abuse_plan.pdf. Accessed May 16, 2013.

Manchikanti L, Malla Y, Wargo BW, et al.: Protocol for accuracy of point of care (POC) or in-office urine drug testing (immunoassay) in chronic pain patients: A prospective analysis of immunoassay and liquid chromatography tandem mass spectrometry (LC/MS/MS). Pain Physician. 2010; 13(1): E1-E22.

Starrels JL, Becker WC, Alford DP, et al.: Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010; 152(11): 712-720.

Committee on Substance Abuse, American Academy of Pediatrics, Council on School Health, et al.: Testing for drugs of abuse in children and adolescents: Addendum–Testing in schools and at home. Pediatrics. 2007; 119(3): 627-630.

Casavant MJ: Urine drug screening in adolescents. Pediatr Clin North Am. 2002; 49(2): 317-327.

American Academy of Pediatrics Committee on Substance Abuse: Testing for drugs of abuse in children and adolescents. Pediatrics. 1996; 98(2 Pt 1): 305-307.

Committee on Bioethics, American Academy of Pediatrics: Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995; 95(2): 314-317.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152(2): 85-92.

Couto JE, Romney MC, Leider HL, et al.: High rates of inappropriate drug use in the chronic pain population. Popul Health Manag. 2009; 12(4): 185-190.

Substance Abuse and Mental Health Services Administration. Office of Applied Studies. Results from the 2007 national survey on drug use and health: National findings. 2008. DHHS publication no. SMA 08-4343.

Ostrea EM Jr, Brady M, Gause S, et al.: Drug screening of newborns by meconium analysis: A large-scale, prospective, epidemiologic study. Pediatrics. 1992; 89(1): 107-113.

Charles BK, Day JE, Rollins DE, et al.: Opiate recidivism in a drug-treatment program: Comparison of hair and urine data. J Anal Toxicol. 2003; 27(7): 412-428.

Gareri J, Klein J, Koren G: Drugs of abuse testing in meconium. Clin Chim Acta. 2006; 366(1-2): 101-111.

Walsh JM, Flegel R, Crouch DJ, et al.: An evaluation of rapid point-of-collection oral fluid drug-testing devices. J Anal Toxicol. 2003; 27(7): 429-439.

Tennant F: Opioid blood levels. Pract Pain Manag. 2011; 11(1): 7.

Gourlay DL, Heit HA, Caplan YH: Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care.

California Academy of Family Physicians. Stanford, CT: PharmaCom Group, Inc, 2010. Available at http://www.pharmacomgroup.com/ udt/udt5.pdf. Accessed May 16, 2013.

Abramowicz M (ed.): Tests for drugs of abuse. Med Lett Drug Ther. 2002; 44(1137): 71-73.

Moeller KE, Lee KC, Kissack JC: Urine drug screening: Practical guide for clinicians. Mayo Clin Proc. 2008; 83(1): 66-76.

Tenenbein M: Do you really need that emergency drug screen? Clin Toxicol (Phila). 2009; 47(4): 286-291.

Hammett-Stabler CA, Pesce AJ, Cannon DJ: Urine drug screening in the medical setting. Clin Chim Acta. 2002; 315(1-2): 125-135.

Bouwmeester NJ, Anderson BJ, Tibboel D, et al.: Developmental pharmacokinetics of morphine and its metabolites in neonates, infants and young children. Br J Anaesth. 2004; 92(2): 208-217.

Luzzi VI, Saunders AN, Koenig JW, et al.: Analytic performance of immunoassays for drugs of abuse below established cutoff values. Clin Chem. 2004; 50(4): 717-722.

Bertholf RL, Bowman MA: Microbeads, magnets, and magic: The enchanting science of immunochemistry. Ann Clin Lab Sci. 1996; 26(5): 377-388.

Reisfield GM, Salazar E, Bertholf RL: Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007; 37(4): 301-314.

Armbruster DA, Schwarzhoff RH, Hubster EC, et al.: Enzyme immunoassay, kinetic microparticle immunoassay, radioimmunoassay, and fluorescence polarization immunoassay compared for drugs-of-abuse screening. Clin Chem. 1993; 39(10): 2137-2146.

Pesce A, West C, Egan-City K, et al.: Toxicity and drug testing. In Diagnostic Accuracy and Interpretation of Urine Drug Testing for Pain Patients: An Evidence-Based Approach. New York, NY: InTech NA. Available at http://www.intechopen.com/books/toxicity-and-drug-testing/urine-drug-testing-in- pain-patients. Accessed May 16, 2013. InTech-Open Access, 2011.

Fraser AD, Meatherall R: Comparative evaluation of five immunoassays for the analysis of alprazolam and triazolam metabolites in urine: Effect of lowering the screening and GCMS cut-off values. J Anal Toxicol. 1996; 20(4): 217-223.

Meatherall R, Fraser AD: Comparison of four immunoassays for the detection of lorazepam in urine. Ther Drug Monit. 1998; 20(6): 673-675.

Meatherall R: Optimal enzymatic hydrolysis of urinary benzodiazepine conjugates. J Anal Toxicol. 1994; 18(7): 382-384.

Straseski JA, Stolbach A, Clarke W: Opiate-positive immunoassay screen in a pediatric patient. Clin Chem. 2010; 56(8): 1220-1223.

Kahan M, Srivastava A, Wilson L, et al.: Misuse of and dependence on opioids: Study of chronic pain patients. Can Fam Physician. 2006; 52(9): 1081-1087.

Katz N, Fanciullo GJ. Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain. 2002; 18(4 Suppl): S76-S82.

Wu AH, Gerona R, Armenian P, et al.: Role of liquid chromatography-high-resolution mass spectrometry (LC-HR/MS) in clinical toxicology. Clin Toxicol (Phila). 2012; 50(8): 733-742.

Levy S, Van Hook S, Knight J: A review of internet-based home drug-testing products for parents. Pediatrics. 2004; 113(4): 720-726.

Rubenstein B, Jen R, Beland C, et al. (eds.): Wiki How to Do Anything: How to Pass a Drug Test. Available at http://www.wikihow.com/Pass-a-Drug-Test. Accessed May 16, 2013.

Jaffee WB, Trucco E, Levy S, et al.: Is this urine really negative? A systematic review of tampering methods in urine drug screening and testing. J Subst Abuse Treat. 2007; 33(1): 33-42.

Levy S, Harris S, Sherritt L, et al.: Drug testing of adolescents in ambulatory medicine: Physician practices and knowledge. Arch Pediatr Adolesc Med. 2006; 160(2): 146-150.

Fang MC, McCarthy EP, Singer DE: Are patients more likely to see physicians of the same sex? Recent national trends in Primary Care Medicine. Am J Med. 2004; 117(8): 575-581.

Vogl W (ed.): Urine Specimen Collection Handbook for Federal Workplace Drug Testing Programs. Rockville, MD: Center for Substance Abuse Prevention. Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. Diane Pub Co, 1996.

Hattab EM, Goldberger BA, Johannsen LM, et al.: Modification of screening immunoassays to detect sub-threshold concentrations of cocaine, cannabinoids, and opiates in urine: Use for detecting maternal and neonatal drug exposures. Ann Clin Lab Sci. 2000; 30(1): 85-91.

US Department of Health and Human Services Mandatory Guidelines and Proposed Revisions to Mandatory Guidelines for Federal Workplace Drug Testing Programs: Notices. Federal Register 69, Washington, DC: US Government Printing Office, 2004: 19659-19660.

West R, Pesce AJ, Crews B, et al.: Determination of illicit drug cutoff values in a pain patient population. Clin Chim Acta. 2011; 412(17-18): 1589-1593.

Pesce A, West C, West R, et al.: Determination of medication cutoff values in a pain patient population. J Opioid Manag. 2011; 7(2): 117-122.

Arnold RM, Han PK, Seltzer D: Opioid contracts in chronic nonmalignant pain management: Objectives and uncertainties. Am J Med. 2006; 119(4): 292-296.

Fishman SM, Bandman TB, Edwards A, et al.: The opioid contract in the management of chronic pain. J Pain Symptom Manage. 1999; 18(1): 27-37.

Fishman SM, Kreis PG: The opioid contract. Clin J Pain. 2002; 18(4 Suppl): S70-S75.

Brasseux C, D’Angelo LJ, Guagliardo M, et al.: The changing pattern of substance abuse in urban adolescents. Arch Pediatr Adolesc Med. 1998; 152(3): 234-237.

Flockhart DA: Drug interactions and the cytochrome P450 system. The role of cytochrome P450 2C19. Clin Pharmacokinet. 1995; 29(Suppl 1): 45-52.

Inciardi JA, Surratt HL, Kurtz SP, et al.: Mechanisms of prescription drug diversion among drug-involved club- and streetbased populations. Pain Med. 2007; 8(2): 171-183.

Fishbain DA, Cole B, Lewis J, et al.: What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008; 9(4): 444-459.

Published

09/01/2013

How to Cite

George, MD, J. A., S. Kost-Byerly, MD, and C. L. Monitto, MD. “Opioid Therapy in Children and Adolescents: A physician’s Guide to Risk Assessment, Monitoring, and Mitigation of Abuse”. Journal of Opioid Management, vol. 9, no. 5, Sept. 2013, pp. 357-68, doi:10.5055/jom.2013.0178.

Issue

Section

Review Articles