The role that prescription opioid use plays in children and teens as a contributor to the development of opioid use disorder is not well defined. One of the reasons for this lack of clarity regarding whether there is a causal association is that most studies are limited by geographic size. This week, to address prior geographic limitations, we are early releasing a study by Chua et al (10.1542/peds.2021-051539) evaluating pediatric opioid prescribing at a national level.
Using a national pharmacy database, the authors analyzed over 4 million prescriptions written for youth ages 0-21 years in 2019 looking for 6 “high-risk” metrics that included the following: the proportion of opioid prescriptions written to opioid-naïve youth that exceeded a 3- or 7-day supply; the proportion of prescriptions used in children 0-11 years that were for codeine or tramadol, which the FDA contraindicated for use in 2017; the proportion of prescriptions written for teens and young adults 12-21 years with daily dosages ≥ 50 morphine milligram equivalents; and the proportion of opioid prescriptions in teens and young adults that overlapped with a benzodiazepine for ≥ 1 day.
There are a lot of interesting findings reported in this study, including the that 3.5% of the population of children and adolescents had an opioid prescription and nearly half fell under one of the high-risk metrics. While most prescriptions were written by dentists and surgeons, 53.3% of opioid prescriptions and 53.1% of those deemed high risk were written by 5% of the providers whose prescription counts were in the 95th percentile.
So how do we take action on the findings in this study? Target the high prescribers with anti-opioid education campaigns? If so, what do we do about the 47% of non-high prescribers who also are prescribing opioids to youths? How worrisome are these findings? Although the media may convey alarm in reporting the findings in this study, an accompanying commentary by Dr. Lucien Gonzalez (10.1542/peds.2021-052190), a pediatric substance use disorder specialist from the University of Minnesota, may convince you otherwise. Dr. Gonzalez tells us that there is no evidence supporting a causal relationship for pediatric opioid prescribing for children in pain and subsequent development of opioid use disorder.
Dr. Gonzalez also points out the limitations of the definition of high-risk metrics. He notes the importance of considering the duration of pain and not just the duration of opioid prescriptions, concerns that the authors used age groupings that overlapped different developmental periods associated with different patterns of risk, and that co-prescribing an opioid with a benzodiazepine in a patient with seizures can be appropriate. The lack of information regarding indications for the use of opioids and the lack of information to better understand if there were biases contributing to the use or nonuse of these drugs in different races and ethnicities could result in a reduction in the high level of concern one might take away from simply looking at the findings as reported by Chua et al.
The study by Chua et al identify the need for more studies to better understand the relationship between opioid prescribing and subsequent opioid use disorder. Check out both the study and commentary to learn more.