While the national opioid crisis is largely viewed as an adult epidemic, those of us in pediatric medicine have seen the devastating effects opioid addiction can have on children.
From infants born to addicted mothers to teenagers abusing prescription medications, these children are relying on us to help them recover and grow into healthy, productive adults.
The support these children require extends beyond standard medical care. At my institution, Nationwide Children's Hospital, clinicians and researchers have developed innovative, integrated approaches with positive results.
Helping Infants in Withdrawal and Beyond
Infants born to opioid-using mothers are at substantial risk for neonatal abstinence syndrome, a constellation of problems that occur when babies experience withdrawal from the drugs they were exposed to in utero. Shortly after birth, symptoms can include inconsolable crying, tremors and hypertonia. Emerging research shows children who had neonatal abstinence syndrome may experience neurodevelopmental and behavioral health consequences into adolescence.
The rate of babies born with neonatal abstinence syndrome has nearly quadrupled since 2004 in the United States. In Ohio alone, it increased more than seven times between 2006 and 2015.
Nationwide Children's has worked to mitigate the short-term withdrawal newborns face and the potential longer-term issues. With our partners in the Ohio Children's Hospital Research Collaborative, we created protocols significantly reducing the length of hospital stay for babies with neonatal abstinence syndrome.
A 2015 study in Pediatrics showed that Nationwide Children's was able to reduce hospitalization for babies requiring pharmacological treatment from 36 days to 18 days. A more recent study published in April 2018 showed that we and our pediatric colleagues in Ohio continue to reduce length of stay and amount of pharmacological treatment. That saves health care dollars, but most importantly, it limits neonatal exposure to opioids after they are born.
Once babies with neonatal abstinence syndrome are discharged from Nationwide Children's, we continue to follow them in our outpatient Neonatal Abstinence Syndrome Clinic and, if necessary, our Early Developmental Follow-up Clinic. Periodic developmental and behavioral testing allow us to identify long-term problems as they emerge and begin interventions as early as possible.
Opioid Use for Pediatric Pain
Opioid prescriptions are avoided whenever possible, but some older pediatric patients may have painful conditions that necessitate long-term opioid use. At Nationwide Children's, these patients are managed in our Comprehensive Pain Management Clinic. Screening for medication misuse is conducted at every appointment in the clinic. Algorithms for managing addiction risk levels ensure appropriate adjustments in patient care.
In 2016, Nationwide Children's also began examining how we prescribe opioids after surgery and in other short-term pain management situations through an Opioid Safety Task Force. Our internal research indicated that we were prescribing more pills than some children needed. Leftover pills were sitting in medicine cabinets, a potential trigger for misuse. We developed a Prescribing and Education Initiative to educate our medical faculty on best prescription practices and to assess patients for abuse after opioids were prescribed.
Our efforts have so far led to a 30 percent reduction in doses per home-going opioid prescription.
Behavioral and Medication-Assisted Treatment
Despite prevention programs, adolescents may still develop addictions, often outside of a medical setting. Traditional drug abuse therapy focuses on behavior: addressing a young adult's motivation to change, providing incentives for abstinence, building skills to resist drug use, and improving problem-solving skills.
A number of studies in recent years demonstrate that combining these behavior therapies with medication-assistant treatment – that is, using drugs such as buprenorphine to suppress withdrawal symptoms and block the euphoric effects of opioids – reduces relapses and is leads to reductions in overdose mortality.
The Nationwide Children's model marries behavioral with medication-assisted therapy, and it goes a step further by integrating this treatment into our primary care clinic. Adolescents often face challenges in addition to addiction, including pregnancy, sexually transmitted infections and depression. Our integrated model supports coordinated care and reduces intake times.
The great majority of young adults who begin traditional treatment programs drop out; less than 10 percent of patients who began our program five years ago remained in it after 12 months. A recent Nationwide Children's initiative involving consistent, determined attention on patient compliance has demonstrated a 40 percent retention rate for patients at 12 months in the program and 60 percent at six months.
Children's hospitals have a responsibility to address the opioid crisis. At Nationwide Children's, we have shown that an, innovative, comprehensive approach can improve lives.
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