Hello. My name is Patricia Schramm. I'm a pediatrician and an addiction medicine specialist, and I work on the Adolescent Substance Abuse Program at Children's Hospital in Boston. It's a pleasure to talk to you today. This is part of the PCOSS training on pain management, and we will be addressing pain medication in adolescents. We would like you to be able, after this lecture, to see all the data that supports that the adolescent is in a vulnerable time to be exposed to opioids. We would like you to develop the skills to provide information about the risks of opioids as an important part of taking care of adolescents, and recognize the many principles about safe opioid prescriptions also pertain to adolescents. We are going to talk a little bit about epidemiology. We are going to talk a little bit about acute pain in adolescents, especially avoid inappropriate use of pain medications, prescribing and use pain medication safely in teens who already have a substance abuse disorder, and identify the teens who are medication-seeking. And we also talk a little bit about chronic pain. In terms of epidemiology, we have to look at and monitor in the future. There is a survey that every single year asks students about a lot of issues, but especially here we are asking of seniors if they had misused opioids in their lifetime. And you can see that around 2002 we had an increase of the number of seniors who were using opioids, and now we had a plateau, and in the last five years it looks like they are using less. Hopefully all the campaigns we are doing about the opioid epidemic is working and they are not using as much, but still they are using 84% of them reported using prescription opioids in their lifetime, and this is still a very high number. The research is showing that the two main reasons why they misuse sometimes is self-medication and sometimes it's just for the euphoria, so recreationally. And it is important to assess the motivation for misusing the medication to guide the appropriate level of intervention. Adolescents are at high risk when they are exposed to opioids. The majority of them who misuse opioids do because they want to treat the pain. These teens will normally screen negative for high-risk substance use, and they are in low risk for having an opioid use disorder. However, the opioids have a very high addiction potential. Adolescents who use them for minor pain may accidentally become addicted, and so the advice and guidance to stop is critical. We recommend that they receive a brief medical advice such as avoid using any pain medication unless it's prescribed by a physician. The opioids may have a lot of side effects, including constipation, nausea, GI upset, and itching, and they are highly addictive. Some people accidentally get hooked quickly. I like to say that it's not because the opioid was prescribed for a grandma who was a petite woman after surgery and she was okay. While my patient is an 18-year-old kid, big and strong and muscular, the difference is the brain development, so the teenager's brain is very susceptible and get hooked to opioids. There are other adolescents who are using these recreationally because of the euphoria and because everyone says that the high is very good. So these are the teens who are at risk of developing a severe substance abuse disorder or an addiction that will require special treatment. The reason that the teenagers are misusing the opioids, here we have a table with the results of the Partnership Attitude Tracking Survey from 2005. They say it's easy to get, it's available everywhere, it's not illegal, it's easy to get through other people's prescriptions. They can claim that the prescription is theirs if they were caught. It's not expensive. They perceive it safer than the other illegal drugs because it's prescribed for by a doctor, it's FDA approved, but they don't know how the brain is so fragile and can be damaged by the medication. Because the brain is still developing. They also say that there is less shame attached to using opioids and they say parents don't care as much as they get caught. If we put it together into groups of reasons, first one is easy to get, second there is no stigma and third they perceive it safer than other drugs and we healthcare providers should instruct them and educate them if this perception is not correct. They are in high risk of becoming addicted. In terms of anticipatory guidance, we need to be attentive because the number of prescriptions of opioids to adolescents has increased dramatically in the last decade. The majority of these prescriptions are not written by the primary care provider. It's written by dentists, emergency department physicians, and orthopedists. Because the adults are at risk, we recommend that in all your adolescent patients and their parents are part of the routine care, you're going to do some anticipatory guidance. So you would explain that at times opioids may be necessary to manage pain. If you ever prescribe it in the opioid, please use exactly as prescribed. Do not share, do not distribute the opioid medication. We highly recommend the parents monitor so they hold and distribute and supervise while the kid is taking the medication and once the need for opioids is resolved, discard any remaining medications. Do not store extra pain medications in the house. In terms of treating pain, we know that opioids are powerful pain medications, but they may have some side effects and high risk potential for misuse, diversion, and addiction. While they can be used safely to treat pain, other and safer alternatives should be considered first. For example, no pharmacologic treatment options, heat, ice, compression, splint, etc. No opioid pain medications like ibuprofen, acetaminophen, other newer no opioid options, and if needed, you can consult with a pain specialist. And a thousand treat underlying mental health disorders, particularly for patients with chronic pain. The anxiety and depression is present. They reduce the pain tolerance and mental health and pain and substance use should be all treated at the same time. In terms of acute pain, first as a pediatrician, we know that acute pain is much more common than chronic pain in pediatrics. We should always maximize non-opioid therapy and avoid opioids for minor trauma, for musculoskeletal pain, headaches, abdominal pain, dysmenorrhea, and other relatively minor self-limited pain that can be managed otherwise. If you prescribe opioids, discuss the side effects and risks. Ensure proper monitoring and keep the prescriptions small and re-evaluated frequently and tell parents they should hold and supervise the medication. Let's go over a few cases so you can have examples of what we recommend. Mark is a 17-year-old boy that has been followed in your office since infancy. He is healthy with no significant past medical history. He presented the office after inverting his ankle during football prep several hours ago. He has diffused swelling and tenderness of the right ankle. His range of motion is normal. There is no point tenderness, and the x-ray reveals soft tissue swelling but no fracture. So you wrap his ankle with ACE bandage and teach him how to use crutch. Your advice, rest, ice, compress, and elevate with adlib weight-bearing but no football practice or physical education for the next week. You prescribe ibuprofen, 400 mg, Q6 PRN for the pain. But he says, I have so much pain. Can I have some Percocet? So every time we have a request for opioids, it's kind of concerning. Is the pain that bad? Is the patient seeking opioids? Does the patient want the opioids for a quick fix? So we need to gather more information and understand the motivation for asking for the Percocet. When you go back to your record, you see the recent health maintenance visit. He reported alcohol use once or twice in the past year and no other substance use. At that time, he received advice to stop drinking. When you ask about rate in his pain, he says it's 2 or 3 out of 10 when he's resting, but shoots up to 8 to 10 with weight-bearing. So the clinician reassures Mark that this is normal pain and advises him to avoid weight-bearing for the next five days while he ankles his. But he says, I have this big game. I cannot miss and I want medication so he can play. So he needs advice. He is in the group of adolescents who is seeking the use of opioids inappropriately for pain control. And in my experience, a lot of football players use opioids so they can continue playing and they ignore the injury. So this is now the brief advice that we recommend for Mark. Acknowledge the pain and make a plan for the pain control. So we need to explain he needs to be no weight-bearing for a few days. He needs the compression. He needs the ice that can speed the healing. Set realistic expectations. Injuries need time to heal. If you rush by ignoring this thing or playing with it, you can end in a very much more severe lesion or even can end your career. So you don't play for the season, you play because of that injury. Involve his parents in the discussion, if at all possible. Let them know the recommendation for Mark to sit out a few days and not play. And follow closely. Re-evaluate if pain is not improved as predicted. Now let's talk about Jessica. Jessica is a 16-year-old girl who has been following your press. She has depression and she is a counselor. She has not been interested in any antidepressant medication. She has a chronic functional abdominal pain. She is being followed by a GI specialist, but she is doing okay. On her last appointment four months ago, ice cream was negative for past use of tobacco, alcohol, or marijuana. Two days ago she was involved in a car accident. She went to the EG, but there were no major injuries. She was advised to take ibuprofen for neuromuscular or musculoskeletal pain. She comes to your office because she has continual neck pain, and she would ask you to prescribe something stronger for it. So Jessica's history is complicated by both this mood disorder and by the chronic pain syndrome, which will make her pain harder to treat. Opioids are not indicated for the treatment of minor musculoskeletal pain. And patients with co-occurring disorders such as the mood disorder are particularly vulnerable to developing substance use disorders. So the clinician needs to ask Jessica, how are you doing since the accident? How is the pain? Is it getting better or worse? Jessica says that she has not been able to get out of bed at all since the accident, except when she comes to this appointment. She has missed two days of school, and her abdominal pain is worse than usual. She is hoping for a different pain medication that will help to treat both so she can go back to school. So opioids are not indicated in this case. She needs supportive, empathic advice and counseling in order to help improve her level of functioning. But you need to reevaluate. Patients with chronic pain disorders can also have a serious injury that should not be overlooked. Acknowledge the pain and set realistic expectations and expect time courses. Reassure her that most injuries get better in a few days. Maximize no pharmacological interventions. So eyes, so hip, neck, collar, and avoid activities such as gym class and doing exercises. Encourage her to get out of bed and return to school. And recommend extra counseling sessions to help Jessica manage the stress. Discuss the plan with parents and offer to see her again in a few days if this didn't work and she still thinks she needs more medication. I feel that always offering, being available makes the patient feel better and they know they can reach us and talk to us again any time they feel they need. Let's talk about Ben. Ben is an 18-year-old boy with a positive family history of alcohol use disorder who recently completed a two-week acute residential treatment program for his alcohol use disorder. Eight days ago he had an open reduction of a tibia fibula fracture that he sustained in a skiing accident. He was discharged with a seven-day prescription for opioid pain medication and today is the first day without the opioid medication and he is complaining of significant pain. He will see the orthopedic in two days and he came to you asking for a refill of his opioid medication. So what should we do? It's clear that he's an obvious source of pain and may benefit from opioid pain medication. However, patients and teenager specialists with a non-substance use disorder, they are in higher risk of becoming addicted to opioids. Even though these same patients and other patients with opioid addiction can be prescribed safely with appropriate monitoring. So again, first thing, re-evaluate the situation. Be sure he doesn't have an infection or surgery complication that is increasing his pain. Stick with the surgery if you think this is the case or if you need a clarification or coordination of care. Ensure that all known pharmacologic treatments possible are maximized. Double-check state prescription registries if available to confirm the number of pills prescribed previously. So this is very, very important. Check your prescription monitoring program to be sure he's not asking for more medication than was prescribed to him and he doesn't have an opioid addiction as well. Set realistic expectations regarding his pain and recovery. And if you decide to prescribe, discuss risks and side effects. Make it very clear they are not supposed to have any alcohol while you're taking opioids. And I would suggest that you write a simple contract that he will take the medication as prescribed and not taking opioids and returning to see you as needed. And letting parents monitor, dispense, and supervise all the medication doses. And keep the prescription small and re-evaluate it frequently. Let's go to another case. So Kayla is a 16-year-old girl who was previously seen just once, 60 years ago, for routine health maintenance. She pretends for an urgent care appointment after slamming her finger in a door. She reports severe, diffuse pain on exam and she has no redness and no swelling. Range of motion appears to be limited by pain. And you diagnose soft tissue injury, recommend ice, body taping, and no steroid anti-inflammatories as needed. She looks at you and says, the pain is so much I can't bear with it and I would like to have a stronger pain medication. So her request for stronger pain medication is concerned, particularly because her pain seems to be out of proportion to your physical examination. Since she is not well known to your practice, you should go do more history and screening. And I think a good way to start is say, I ask any one of my patients these questions before I prescribe any medication. So you do a screening for substance use and she reports daily tobacco use and monthly alcohol and marijuana use. And she had used a few other pain medications once or twice in the past year and denies use of any of these substances. When you ask about the medication, she said she was experimenting with her friends, but she stopped experimenting because one of her friends overdosed, which scared the entire group. So Kayla's history of tobacco, alcohol, marijuana, and opioid use put her at high risk for substance use disorder. Based on this presentation, we should be concerned that she may be seeking for opioid prescription for misuse or diversion and she may even have already an opioid use disorder. So again, acknowledge the pain, discuss pain control, and set realistic expectations. Discuss why opioids are not indicated for minor soft tissue injuries. Tell Kayla that you are concerned and you'd like to discuss her substance use more. And this is an opportunity for a brief intervention. So we recommend screening, brief intervention, and refer to treatment for every patient when you do a routine care for adolescents and for any urgent care appointment that you have any concerns about substance use. And explain to Kayla that some kids get addicted by accident, that their brain is too vulnerable, even just after using a few times. Tell her if she's concerned she may have a drug problem that you can help and ask to include her parents in this conversation. Now let's go over and start talking about chronic pain. Chronic pain is relatively uncommon in pediatrics. And most of the patients are co-managed with specialists and this treatment needs coordination. Primary care providers may ask to follow along with medication, to refuse, provide some guidance and parents, refer if the course of the illness changes. Why developing an addiction in the course of closely monitored pain management is rare. Adolescents should be watched closely for developing signs of addiction. So let's talk about Lisa. Lisa is a 16-year-old athlete with spondylolisis and she is still conservative management with no steroid anti-inflammatory. She is wearing a back brace and surgery is planned in six months. Her orthopedist prescribed opioids three weeks ago to help her manage her back pain. She represents for a group routine appointment in primary care office and reports that she's having difficulty despite the medication being prescribed and she's taking the opioids. So again, let's go look at carefully and decide what to do. So she has an identified source of pain, but it seems that it's not responding to the management, even with the opioid therapy. The differential diagnosis includes progression of the disease process, depression or a mental health disorder interfering with the treatment and the functioning or the medication thinking and developing of a substance use disorder. So we needed to talk to her carefully, get more information. So you interviewed Lisa privately, so we needed to be sure the conversation is confidential. She likes the school although she nearly missed the three weeks due to the pain. She spends most of her days lying down. A tutor comes home three times a week so she can keep up. She has been using social networking to keep up with her friends. She enjoys watching movies when she's feeling relatively better. She denies past use of tobacco, alcohol or marijuana. She has never misused, sold or shared her prescription medication. In fact, she notes that her mother keeps the medication locked up and only gives her once a day. So what would be the signs of addiction when you talk to the patient? So when you talk to Lisa, she's denying high risk behaviors that are the ones that we are going to go over now. She is very precise of her history. She is not someone who tells stories, very effusive on the information she gives to you. She has been followed by only two doctors and not going to the emergency room visits for pain and doctor shopping. She is not buying pain medication illicitly. She is not forging prescriptions. She is not escalating those or use of medication by an alternative route. And she's not combining pain medication with other drugs. It seems that Lisa is following the recommendations that were given by the doctor. But we need to talk to her mother to confirm this story and be sure that she's giving the medication according to the prescribed pain plan. So the mother says she doesn't believe that Lisa uses tobacco, alcohol, marijuana or has misused her prescription medication. She confirms that she, the mother, is not giving the full prescribed dose because she has heard the medications are very addictive and she is concerned. She tells you that the paternal ankle has a substance use disorder and she thinks that Lisa may be depressed. His mood is often low and she spends a lot of time trapped in that. So it seems here that the mother is not following the plan that was given. And it seems that Lisa is being undertreated for her pain. She may also have symptoms of a mood disorder, but now we need to put Lisa and her mother together and talk. So we should acknowledge the concerns about opioid addiction. We know that they have addiction potential and should be used with caution and being monitored. You give Lisa's mother a brief overview of opioid biology and explain that pain can be safely treated. We recommend that Lisa take the pain education that was being prescribed to her, not only once a day, to see if she can get out of bed and back to school. As with all the patients, you ask Lisa and her mother to sign a pain education contract and you ask Lisa to return in one week for a follow-up and to meet with a social worker in your office for emotional support. So let's talk about safe prescribing. And you may refer for more information to the module about risk assessment and mitigation. So safe prescribing, we should have only one prescribed physician and only one pharmacy. Limit early refills and lost or stolen prescriptions. Never change the dose or the frequency of anything without consulting the doctor who prescribed it. Do sporadic pill counts. The parents should hold all the medications all times and supervise the dosing. We need to ask the adolescent to report the symptoms and side effects honestly. Report any emergency room visits. We should monitor for illicit drug use with the urine drug test if we have any concerns and never obtain any narcotic opioids illicitly. So Lisa's follow-up is one week. Her mother has given her the pain medication as prescribed and she is a bit better. She still has pain, but she was able to get out of bed and go to school. She complains of constipation and nausea and asks if the medication can be changed. You agreed to drop the dose a little bit and she saw the social work and thought the conversation was useless and she agreed to come back and see the social work weekly for counseling. So Lisa got better the moment you gave the opioids and this is what we call the undertreatment of pain or what here we are putting on this table, the not good pain management versus opioid use disorder. So the patient that the pain is undertreatment, when you give the right treatment, you give the opioid dysfunction improved. However, the one who has opioid use disorder, there is no change in functioning with the treatment. The side effects of opioids, the constipation and the nausea and other ones, they bother them and the ones who have opioid use disorder have minimal or no side effects or they ignore the side effects completely. With the patient that you're treating, the pain, it's easy to stabilize. Just take a few visits, supervision and you can do, but the one who has an addiction will constant request for a dose escalation. The patient who is being treated by pain normally could have some leftover medication and the other patient with addiction with no leftover medication and will be frequently request early refills. In the beginning of the course of treatment, it could be difficult to distinguish between these two patients. We always recommend that you err in the side of prescribing a shorter course than a longer course of medication and then you ask for frequent returns. We recommend a small opioid prescription because a small opioid short term is unlike to change the course of an opioid use disorder, but if the patient is being under treatment for pain, we really increase the pain, increase the functioning and improve the life of the patient and improve the function. In summer, adolescence is a vulnerable time to be exposed to opioids and we should always use non-opioid therapies and we should always explain to the patient and educate them why we do not recommend opioid therapy, talk about the vulnerable brain and work with other kinds of therapies. Providing the information to educate about the risk of opioids is an important component of treating adolescence and many principles about safe opioid prescribing pertain to adolescence as well as adulthood. And very important in every well care visit for teenagers or in the visits that you are concerned, do screening, brief intervention and refer to treatment. Here we have the references and here we have the information of the PCSSO support program. If you have any questions, if you want to communicate with us, we will be happy to support you and talk to you. If you have any questions, please communicate with the program. Here is the site. Thank you for your attention.

Dr. Patricia Schramm

adolescents

pain medication

opioid exposure

misuse of opioids

adolescent pain management

safe prescribing practices