As physicians today, we find ourselves in an increasingly complex healthcare environment, one that requires us to juggle multiple roles and responsibilities. We have our patient care first and foremost, but we’re also often called on to be people managers, business owners, medical educators and even compliance officers.
That juxtaposition of roles is never more evident than in the duality of opioids – appropriate prescribing and preventing abuse. Like all medications, opioids were developed with the best of intentions – helping patients. But unfortunately, as we’ve seen firsthand, abuse of a drug intended for good has wreaked havoc on our societies, communities and families.
As a pediatrician, I have seen the spike in opioid abuse in teens, adolescents and children over the last several years. Clearly this is not news to my colleagues, but it doesn’t make it any less alarming. Research presented at the 2017 American Academy of Pediatrics (AAP) National Conference showed the number of pediatric patients testing positive for opioid addiction or dependency in U.S. ERs increased by more than half between 2008 and 2013, and that 100 or more children test positive for opioid addiction or dependency each day.¹ While there have been a few positive signs that we’re making headway, it’s still not surprising that the 2019 AAP National Conference will include a heavy focus on the issue of opioids in our patient population.
I believe pediatricians will be called upon to become more involved in this fight to curb opioid abuse among our young patients. In fact, given the lack of behavioral health and substance abuse resources for kids, there have even been calls to expand our role, creating a more multidisciplinary environment and offering behavioral and medication resources to treat dependencies within our practices.²
Over my years in pediatrics, I have seen opioid dependence or abuse generally start on one of four paths:
- Infants with Neonatal Abstinence Syndrome (NAS) who are born suffering from withdrawal;
- Adolescents or teens who have diverted a relative’s or caretaker’s prescription for themselves;
- Kids who procure drugs from other kids, or from adults selling them, leading to addiction;
- Frequent or sustained opioid prescribing by their primary care physician or specialist.
Within that admittedly high-level framework, I believe there are six basic practice standards we should remind ourselves of for the protection of our patients, our staff, our practices and even ourselves:
Education, education and more education: There are a multitude of CME options around opioid abuse, from highly specialized training on NAS and newborn addiction, to better recognizing signs of substance abuse, to appropriate prescribing, to the latest medication-assisted treatment (MAT) protocols. I believe it is essential for physicians to take advantage of educational opportunities, regardless of how much opioid abuse seen (or not seen) in individual practices. But education shouldn’t be limited to us. Appropriate training on opioid prescribing, abuse prevention and especially documentation and tracking must be standard for every patient touchpoint in the office – nurse practitioners, physician assistants, medical assistants, even front office staff.
Knowing the signs: Most doctors by now are trained to recognize substance dependence in our patients, but I believe that recognition needs to also encompass those in charge of the child. I recently saw an adolescent patient who came in with a father who was adamant that I prescribe opioids to manage the child’s hip pain that had occurred from a sports injury. The child had already been prescribed pain relievers from the orthopedist and the father was requesting refills because the pain wasn’t better. The incident raised flags for me, especially given the belligerent attitude of the parent. As pediatricians we are well-trained to see signs of physical abuse, but we don’t always diligently look for signs of a child’s opioid misuse by a parent. As regulations tighten around prescribing opioids, this is likely to become more common.
Understanding pain relief options: We’ve long heard the message that pediatric patients are being prescribed opioids too often and for too long. And a recent study stated that opioids were prescribed in about 15% of ED visits and 3% of outpatient clinic visits for adolescents and young adults.³ I believe as the child’s primary caregivers, we should always err on the side of conservative pain management. We also have the advantage of relationship and being able to monitor our patients pain if not improving. Know your options before prescribing opioids and be judicious in refilling a prescription that may have originated with another provider such as a surgeon.
Patient and family conversation: If you aren’t having a conversation about addiction and opioid risks every time you prescribe them, you should be. Conversations should be with both patients and their parents or guardian. Use that opportunity to also talk about safe drug storage of any opioids and discourage any sharing. Some studies have found that leftover medical prescriptions, or prescriptions for family members or friends are the most common sources of misused prescription opioids.
Due Diligence matters: Putting on the hat of a practice owner and partner, I’m a firm believer in the power of the electronic medical record. Each month, I get a report that tells me how many controlled substances were prescribed, to whom and for how long. We all get busy with patients, but I think it’s incumbent on us to consistently monitor our reports. Not just for our own prescribing, but also for those who may use our DEA numbers to prescribe. In a large practice, there may be multiple touch points of prescription and we need to be aware of them all, and monitor them closely to ensure we are aware of all opioid prescribing.
Watching every care point: Many pediatric practices now are offering extended, weekend hours and urgent care resources. This often means finding PRN staffing to fill those hours. So, while you may have a good handle on the prescribing of your full-time staff, make sure you also understand what is happening at all points of care.
As doctors, our first commitment is to provide quality care to our patients. In today’s environment, that means playing multiple roles and ensuring your practice processes and standards are at the same level of quality as your clinical care.
¹ Opioid abuse in children: An emerging public health crisis! Veerajalandhar Allareddy, Sankeerth Rampa, Romesh P. Nalliah, Veerasathpurush Allareddy
² Pediatric primary care could be key to solving teen opioid crisis, AMA Connect, August 24, 2017 by Andis Robeznieks, Senior News Writer, American Medical Association
³Trends in Opioid Prescribing for Adolescents and Young Adults in Ambulatory Care Settings (Hudgins JD, et al. Pediatrics. May 28, 2019, https://doi.org/10.1542/peds.2018-1578).