Considerations of non-medical use of prescription opioids (NMUPO) in pediatric pain management
Stephanie Jane Dowden
Since the 1990’s there has been a significant increase in opioid prescribing and both medical and non-medical use of prescription opioids (NMUPO) with associated high rates of morbidity and mortality (Ling et al., 2011; Manchikanti et al., 2012a). This commentary will discuss NMUPO and considerations for pediatric pain management clinicians.
NMUPO is defined as “the taking of prescription drugs [opioids], whether obtained by prescription or otherwise, other than in the manner or for the reasons or time period prescribed, or by a person for whom the drug was not prescribed” (United Nations Office on Drugs and Crime [UNODC], 2011, p. 1). NMUPO ranges from recreational use to self-medication and is not necessarily associated with substance use disorders (Boyd & McCabe, 2008; Frese & Eiden, 2011).
The morbidity and mortality from NMUPO are significant and rising. In 2011, 29% of emergency department (ED) visits for drug-related misuse or abuse in the United States were due to NMUPO, with 25% requiring admission to hospital (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). Oxycodone, hydrocodone and methadone were the most common opioids identified (SAHMSA, 2013). NMUPO-related ED presentations increased by 132% from 2004 to 2011, with peak incidence in 18- to 20-year-olds; however, presentation rates remain elevated between 18 and 55 years of age, dispelling the view that NMUPO-related risk is isolated to youth (SAHMSA, 2013). Prescription opioids are the causative drug in 14% of ED presentations for suicide attempts in adolescents. Additionally, 46% of people presenting to an ED seeking referral to detox services are due to NMUPO (SAHMSA, 2013). Overdose deaths from prescription opioids (either alone or in combination with other drugs) have tripled in the United States in the last 20 years, being responsible for 16,651 deaths (74% unintentional, 17% suicide) in 2010 with highest incidence between 20 and 59 years of age, peaking between 40 and 49 years of age (Jones et al., 2013; Mack, 2013).
Sources of prescription opioids and NMUPO prevalence in adolescents
Opioid prescribing for children and adolescents is growing, although rates are low compared to adults. Fortuna et al. (2010) found a 45% increase in young people being prescribed controlled medications (i.e. opioids, stimulants and sedatives) in the United States over a 13 year period. Richardson et al.’s (2011) survey of opioid prescribing trends reported increasing rates of opioids prescribed for adolescents with musculoskeletal pain and headaches. They noted even higher prescribing rates for adolescents with comorbid mental health disorders or multiple pain conditions.
Adolescents commonly obtain prescription opioids from family or friends rather than illegal sources (UNODC, 2011; McCabe et al., 2012a). Ross-Durow et al. (2013) identified adolescents’ access to medications as a risk factor for misuse. They found 73% of adolescents prescribed controlled drugs in the previous 6 months had unsupervised access to them at home.
McCabe et al. (2012a,b) studied medical and non-medical use of opioids in senior high school students (mean age 18 years) in the United States. Prevalence of NMUPO ranged from 12.3 to 12.9%. Of concern, 70% of those who reported NMUPO co-ingested other drugs (McCabe et al., 2012b). Nakawaki and Crano’s 2012 study of adolescents (n = 126,764) aged 12 to 17 years in the United States found persistent use of common illicit substances were the greatest predictor of NMUPO. Fischer et al. (2013) assessed prevalence of NMUPO in Canada and described rates of 15.5% in adolescents (secondary-school aged, n = 3266) and 5.9% in adults (over 18 years, n = 4023). Hibell et al. (2012) reviewed substance use among adolescents in 36 European countries (n = 100,000); with mean age 15.8 years and found rates of 7-8%. McCabe et al.’s 2014 longitudinal study (n = 27,268) examined 18- to 24-year-olds’ patterns of NMUPO over time. There was increased likelihood of chronic patterns of NMUPO at ages 23 to 24 years when associated with multiple problematic substance use behaviors (i.e. binge drinking, marijuana use and non-medical use of other prescription drugs).
Motives for NMUPO
The most commonly reported motive for NMUPO in adolescents is self-medication of pain or insomnia, which may not relate to other misuse behaviors (Zacny & Lichtor, 2008; McCabe et al., 2013). Conversely, NMUPO for recreational reasons (e.g. to get high or experiment) is highly correlated with use of other drugs and binge drinking and associated with increased risk for substance use disorders (Young et al., 2012; McCabe et al., 2013). There is evidence that adolescents experiment with NMUPO rather than illicit drugs due to their availability and being socially acceptable. In addition, adolescents consider prescription drugs to be safer than illicit drugs because health professionals prescribe them, they are purchased from pharmacies, and they are used by family or friends (Compton & Volkow, 2006; Oliver et al., 2012).
Identifying vulnerable adolescents
UNODC (2011) and Young et al. (2012) found female gender increased risk of NMUPO. Veliz et al. (2013) reported greater risk in adolescents competing in high-injury sports (notably football and wrestling) while Young et al. (2011) identified adolescent girls who experienced sexual victimization having up to five-fold risk of NMUPO compared to peers, depending on assault severity.
There is minimal evidence of NMUPO or substance use disorders in adolescents with sickle cell disease or hemophilia; but, they may be at risk due to the unrelenting nature of their pain and its undertreatment because of perceived fears of addiction (Zempsky, 2010; Witkop et al., 2012). Significantly, there is some evidence that denying prescription opioids to youth whose pain symptoms are comorbid with substance use disorders increases their likelihood of self-medication and escalation to higher risk behaviors (Fibbi et al., 2012).
Risk assessment and harm reduction
A range of tools is available to assess risk (Oliver et al., 2012) when considering opioid prescription to adolescents. Two tools validated for adolescents, the CRAFFT Screening Tool for Adolescent Substance Abuse (Knight et al., 1999; Dhalla et al., 2011) and the Drug Abuse Screening Test, Short Form (DAST-10; Addiction Research Foundation, 1982), are recommended by McCabe et al. (2012c) to identify the subgroup at highest risk for substance use disorders and the subgroup who would benefit from pain management. Knight et al. (2007) found that adolescents preferred to self-screen using paper or computer-based tools versus face-to-face with a doctor or nurse; also self-screening had higher rates of honesty and reliability. Additionally, a detailed patient and family history should be obtained to determine comorbidities (i.e. depression, anxiety and other risk factors such as family history of substance use disorders; Frese & Eiden, 2011; Oliver et al., 2012).
Key to harm reduction is discussion about NMUPO, despite 50% of clinicians reporting they find this difficult (The National Center on Addiction and Substance Abuse [CASA], 2005). It is imperative to educate adolescents and their parents about safety and risks of opioids, danger of combining opioids with other substances, diversion, safe storage, supervised access and disposal of unused opioids.
Striking a balance: pain relief and NMUPO
Although opioids have been shown to have some efficacy for adult neuropathic pain (Moulin et al., 2007) there is limited evidence of their usefulness for persistent non-cancer pain in all ages (Ling et al., 2011; Kotalik, 2012). Indeed, careful prescribing for acute pain and not prescribing opioids for persistent non-cancer pain in adolescents may be the most prudent strategy (UNODC, 2011; Kahan et al., 2012).
Safe prescribing and monitoring
Internationally, opioid prescribing guidelines have been produced by organizations such as The American Society of Interventional Pain Physicians (Manchikanti et al., 2012b,c). Furthermore, countries and regions have implemented recommendations to improve practice (Juurlink et al., 2013; Nuckols et al., 2014) and established prescription drug monitoring programs to track opioid prescribing and dispensing.
Urine drug testing (UDT) is used by clinicians prescribing opioids for adults with chronic pain. For optimal effect it is suggested that all patients are screened instead of only using UDT for at-risk patients (Heit & Gourlay, 2004). Peppin et al. (2012) summarize urine-screening recommendations for long-term opioids. There is little data on UDT for adolescents with chronic pain and some suggestion that it is being overlooked (Saroyan et al., 2011).
Opioid contracts or agreements are often mandated; however, ethical concerns about their usefulness have been raised (Payne et al., 2010). It is important to note that evidence for efficacy of opioid monitoring strategies is limited with research in this area evolving rapidly (Manchikanti et al., 2012b,c; Nuckols et al., 2014).
Suggested management for adolescents with chronic pain
What to do if a patient is demonstrating NMUPO
Clinicians must pay attention to recognizing adolescents who develop substance use disorders. When substance use disorders are identified, advice should be sought from pain management and addiction specialists with referral to drug treatment programs for concurrent treatment. Rates of referrals to drug treatment programs are low, often delayed until adolescents are in crisis and via the criminal justice system, resulting in preventable and costly health and social problems (CASA, 2011, 2012). Review Oliver et al. (2012), Miotto et al. (2012) and Chang and Compton (2013) for further details about how to manage pain in patients with concurrent substance use disorders.
Cite as: Dowden SJ. Considerations of non-medical use of prescription opioids (NMUPO) in pediatric pain management. Pediatric Pain Letter 2014;16(1-2):15-21. www.childpain.org/ppl
Addiction Research Foundation. Drug Abuse Screening Test (DAST-10). Author, 1982. Link
Boyd CJ, McCabe SE. Coming to terms with nonmedical use of prescription opioids. Subst Abuse Treat Prev Policy 2008;3:22. PubMed Abstract
Chang YP, Compton P. Management of chronic pain with chronic opioid therapy in patients with substance use disorders. Addict Sci Clin Pract 2013;8:21. PubMed Abstract
Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend 2006;81:103-107.
Dhalla S, Zumbo BD, Poole G. A review of the psychometric properties of the CRAFFT instrument: 1999-2010. Curr Drug Abuse Rev 2011;4:57-64. PubMed Abstract
Fibbi M, Silva K, Johnson K, Langer D, Lankenau SE. Denial of prescription opioids among young adults with histories of opioid misuse. Pain Med 2012;13:1040-1048. PubMed Abstract
Fischer B, Ialomiteanu A, Boak A, Adlaf E, Rehm J, Mann RE. Prevalence and key covariates of non-medical prescription opioid use among the general secondary student and adult populations in Ontario, Canada. Drug Alcohol Rev 2013;32:276-287. PubMed Abstract
Fortuna RJ, Robbins BW, Caiola E, Joynt M, Halterman JS. Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics 2010;126:1108-1116. PubMed Abstract
Frese WA, Eiden K. Opioids: nonmedical use and abuse in older children. Pediatr Rev 2011;32:e44-e52.
Heit HA, Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage 2004;27:260-267. PubMed Abstract
Hibell B, Guttormsson U, Ahlström S, Balakireva O, Bjarnason T, Kokkevi A, et al. The 2011 ESPAD report. Substance use among students in 36 European countries. Stockholm, Sweden: The Swedish Council for Information on Alcohol and Other Drugs, 2012. Link
Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA 2013;309:657-659. PubMed Abstract
Juurlink DN, Dhalla IA, Nelson LS. Improving opioid prescribing: the New York City recommendations. JAMA 2013;309:879-880. PubMed Abstract
Kahan M, Wilson L, Mailis-Gagnon A, Srivastava A, National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 2: special populations. Can Fam Physician 2011;57:1269-1276, e419-e428. PubMed Abstract
Knight JR, Harris SK, Sherritt L, Van Hook S, Lawrence N, Brooks T, et al. Adolescents’ preference for substance abuse screening in primary care practice. Subst Abus 2007;28:107-117. PubMed Abstract
Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 1999;153:591-596. PubMed Abstract
Kotalik J. Controlling pain and reducing misuse of opioids: ethical considerations. Can Fam Physician 2012;58:381-385, e190-e195. PubMed Abstract
Ling W, Mooney L, Hillhouse M. Prescription opioid abuse, pain and addiction: clinical issues and implications. Drug Alcohol Rev 2011;30:300-305. PubMed Abstract
Mack KA; Centers for Disease Control and Prevention (CDC). Drug-induced deaths - United States, 1999-2010.MMWR Surveill Summ 2013;62(Suppl 3):161-163. PubMed Abstract
Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 1 - evidence assessment. Pain Physician 2012b;15(Suppl 3):S1-S66. PubMed Abstract
Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2 - guidance. Pain Physician 2012c;15(Suppl 3):S67-s116. PubMed Abstract
Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V, Grider JS, et al. Opioid epidemic in the United States. Pain Physician 2012a;15(Suppl 3):ES9-ES38. PubMed Abstract
McCabe, SE, Schulenberg JE, O’Malley PM, Patrick ME, Kloska DD. Non-medical use of prescription opioids during the transition to adulthood: a multi-cohort national longitudinal study. Addiction 2014;109:102-110. PubMed Abstract
McCabe SE, West BT, Boyd CJ. Medical use, medical misuse, and nonmedical use of prescription opioids: results from a longitudinal study. Pain 2013;154:708-713. PubMed Abstract
McCabe SE, West BT, Teter CJ, Boyd CJ. Medical and nonmedical use of prescription opioids among high school seniors in the United States. Arch Pediatr Adolesc Med 2012a;166:797-802. PubMed Abstract
McCabe SE, West BT, Teter CJ, Boyd CJ. Co-ingestion of prescription opioids and other drugs among high school seniors: results from a national study. Drug Alcohol Depend 2012b;126:65-70. PubMed Abstract
McCabe SE, West BT, Teter CJ, Cranford JA, Ross-Durow PL, Boyd CJ. Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addict Behav 2012c;37:651-656. PubMed Abstract
Miotto K, Kaufman A, Kong A, Jun G, Schwartz J. Managing co-occurring substance use and pain disorders. Psychiatr Clin North Am 2012;35:393-409. PubMed Abstract
Moulin DE, Clark AJ, Gilron I, Ware MA, Watson CP, Sessle BJ, et al. Pharmacological management of chronic neuropathic pain - consensus statement and guidelines from the Canadian Pain Society. Pain Res Manag 2007;12:13-21. PubMed Abstract
Nakawaki B, Crano WD. Predicting adolescents’ persistence, non-persistence, and recent onset of nonmedical use of opioids and stimulants. Addict Behav 2012;37:716-721. PubMed Abstract
The National Center on Addiction and Substance Abuse at Columbia University. Under the counter: the diversion and abuse of controlled prescription drugs in the U.S. New York: Author, 2005. Link
The National Center on Addiction and Substance Abuse at Columbia University. Adolescent substance use: America’s #1 public health problem. New York: Author, 2011. Link
The National Center on Addiction and Substance Abuse at Columbia University. Addiction medicine: closing the gap between science and practice. New York: Author, 2012. Link
Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med 2014;160:38-47. PubMed Abstract
Oliver J, Coggins C, Compton P, Hagan S, Matteliano D, Stanton M, et al. American Society for Pain Management nursing position statement: pain management in patients with substance abuse disorders. Pain Manag Nurs 2012;13:169-183. PubMed Abstract
Payne R, Anderson E, Arnold R, Duensing L, Gilson A, Green C, et al. A rose by any other name: pain contracts/agreements. Am J Bioeth 2010;10:5-12. PubMed Abstract
Peppin JF, Passik SD, Couto JE, Fine PG, Christo PJ, Argoff C, et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Med 2012;13:886-896. PubMed Abstract
Richardson LP, Fan MY, McCarty CA, Katon W, Edlund M, DeVries A, et al. Trends in the prescription of opioids for adolescents with non-cancer pain. Gen Hosp Psychiatry 2011;33:423-428. PubMed Abstract
Ross-Durow PL, McCabe SE, Boyd CJ. Adolescents’ access to their own prescription medications in the home. J Adolesc Health 2013;53:260-264. PubMed Abstract
Saroyan JM, Cheng WY, Taylor DC, Afzal A, Sonty N, Sullivan MA. Select practice behaviors of clinicians on the use of opioids for adolescents with subacute and chronic nonmalignant pain. J Opioid Manag 2011;7:123-134. PubMed Abstract
Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: national estimates of drug-related emergency department visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Author, 2013. Link
United Nations Office on Drugs and Crime. The non-medical use of prescription drugs: policy direction issues. Vienna, Austria: United Nations, 2011. Link
Veliz PT, Boyd C, McCabe SE. Playing through pain: sports participation and nonmedical use of opioid medications among adolescents. Am J Public Health 2013;103:e28-e30. PubMed Abstract
Witkop M, Lambing A, Divine G, Kachalsky E, Rushlow D, Dinnen J. A national study of pain in the bleeding disorders community: a description of haemophilia pain. Haemophilia 2012;18:e115-e119. PubMed Abstract
Young A, Grey M, Boyd CJ, McCabe SE. Adolescent sexual assault and the medical and nonmedical use of prescription medication. J Addict Nurs 2011;11:25-31. PubMed Abstract
Young AM, Glover N, Havens JR. Nonmedical use of prescription medications among adolescents in the United States: a systematic review. J Adolesc Health 2012;51:6-17. PubMed Abstract
Zacny JP, Lichtor SA. Nonmedical use of prescription opioids: motive and ubiquity
Zempsky WT. Evaluation and treatment of sickle cell pain in the emergency department: paths to a better future. Clin Pediatr Emerg Med 2010;11:265-273. PubMed Abstract