Treatment of opioid use disorder
As problems with opioid use and abuse in the United States increasingly emerge to create what is being called a public health epidemic, clinicians are facing the great challenge of trying to provide optimal pain management for their patients while being mindful of the potential deleterious effects of the highly addictive opioids.
As problems with opioid use and abuse in the United States increasingly emerge to create what is being called a public health epidemic, clinicians are facing the great challenge of trying to provide optimal pain management for their patients while being mindful of the potential deleterious effects of the highly addictive opioids. When used properly, these drugs provide great pain relief, but their easy misuse and abuse create a cascade of problems that has led to current debates on their appropriate and best use for pain management.
Within this larger debate is the difficult issue of how to treat patients who become dependent or addicted to opioids. For pediatricians and other healthcare providers who care for children who develop an opioid dependence or addiction, the challenge to treat this dependence is all the greater given the lack of good guidelines geared particularly for children and adolescents.
Conflicting guidelines for kids
The need for guidance is critical. Prescription of opioids to US children for medical reasons has doubled over the past decade, with the majority of opioids prescribed for postprocedural and postoperative use in children aged between 10 and 17 years.1 In 2009, more than 7 million prescriptions for opioids were dispensed for children. Accompanying this increase in opioid prescriptions are the numbers that tell the problem. According to data from the Centers for Disease Control and Prevention (CDC), nearly 2 million people in the United States aged 12 years and older either abused or became dependent on opioids in 2013.2 In addition, 2.6 of 100,000 persons in the United States aged between 15 and 24 years died from an overdose of prescription opiods.
The recently published 2016 guideline from the CDC on prescribing opioids for chronic pain, which includes a recommendation for evidence-based treatment for opioid use disorder, provides needed guidance for adults, and it explicitly states that the guidelines apply only to patients aged 18 years or older.3 However, as emphasized in an accompanying editorial, pediatricians and primary care providers should take care not to extrapolate from this evidence geared toward adults and tailor it inappropriately, and perhaps with detriment, to children and adolescents.2
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In 2014, the American Academy of Pediatrics (AAP) published a clinical report on management strategies for weaning children and adolescents off opioids (at the same time emphasizing the lack of clear evidence on a single ideal protocol). Highlighted is the need for gradual dose reduction without abrupt drug discontinuation.1 Although no management strategies were provided for how to treat children and adolescents who become dependent on or addicted to opioids, the clinical report does reference data from treatment programs for adolescents who are dependent on prescription opioids or heroin that include behavioral intervention in their treatment programs. (For the description of an attempt by a US tertiary care children’s hospital to standardize management of iatrogenically induced opioid dependence and withdrawal, see “Treatment of opioid dependence: Protocol developed at a tertiary care children’s hospital”)
NEXT: Distinction between opioid dependence and addiction
Although no singular guideline exists that specifically focuses on treatment of opioid dependence or addiction in children and adolescents, a recently published guideline by the American Society of Addiction Medicine (ASAM) on the use of medications to treat addiction involving opioid use includes a specific section on treatment for adolescents.5
This article summarizes key treatment strategies from the ASAM guideline. The aim of this article is not to provide a single approach or guideline on how to treat opioid dependence or addiction in children (as none yet exists), but to arm pediatricians with some basic understanding of treatment considerations as they either refer their patients to or collaborate with addiction specialists to provide the best treatment possible for their patients.
ASAM treatment guidelines
Published in 2015, the ASAM practice guideline focuses on the use of medications to treat addiction involving opioid use and provides a number of clinical recommendations based on 13 different areas (or parts).5 These areas include assessment and diagnosis; treatment options; treating opioid withdrawal; methadone; buprenorphine; naltrexone; psychosocial treatment in conjunction with mediations for the treatment of opioid use disorder; special populations (pregnant women, individuals with pain, adolescents, individuals with co-occurring psychiatric disorders, individuals in the criminal justice system); and naloxone for the treatment of opioid overdose.
This article only summarizes those areas most relevant to pediatricians and other healthcare providers in treating opioid dependence or addiction in children and adolescents. Tables 1 and 2 summarize clinical recommendations that pertain to all populations with opioid dependence, and can be relevant for (but are not specific to) children and adolescents. These tables provide only a brief summary, therefore readers are urged to read the full clinical guideline. Table 3 summarizes recommendations specific for adolescents.
NEXT: ASAM guidelines
Summary
To date, no singular guideline exists on treatment of opioid dependence or addiction in children and adolescents. Current guidelines on opioid use and treatment are geared primarily for adults, and their extrapolation to children should be avoided because little data is available on the specific effects of opioids on the developing mind and the optimal approach to treating dependence or addiction. Pediatricians and other healthcare providers who care for children and adolescents can use the information here as a starting point to better understand how to approach the management of opioid dependence or addiction in children.
Next: How nonmedical opioid use increases sexual risks
REFERENCES
1. Galinkin J, Khol JL; Committee on Drugs; Section on Anesthesiology and Pain Medicine; American Acedemy of Pediatrics. Recognition and management of iatrogenically induced opioid dependence and withdrawal in children. Pediatrics. 2014;133(1):152-155.
2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016. JAMA. 2016;315(15):1624-1645.
3. Schechter NL, Walco GA. The potential impact on children of the CDC Guideline for Prescribing Opioids for Chronic Pain: above all, do no harm. JAMA Pediatr. 2016. 170(5):425-426.
4. Abdouni R, Reyburn-Orne T, Youssef TH, Haddad IY, Gerkin RD. Impact of a standardized treatment guideline for pediatric iatrogenic opioid dependence: a quality improvement initiative. J Pediatr Pharmacol Ther. 2016;21(1):54-63.
5. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med. 2015;9(5):358-367.
Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has over 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.
