Hello, everyone. My name is Elliot Crane. Welcome to today's activity titled Pain Medication and Adolescence, Special Considerations. This event is brought to you by the Provider's Clinical Support System, Medications for Opioid Use Disorders Project, PCSS MOUD. Content and discussions during this event are prohibited from promoting or selling products or services that serve professional or financial interests of any kind. The overarching goal of PCSS MOUD is to increase healthcare professionals' knowledge, skills, and confidence in providing evidence-based practices in the prevention, treatment, recovery, and harm reduction of opioid use disorder, OUD. At the conclusion of this activity, participants should be able to review data regarding the development of OUD during adolescence, develop skills to provide information about the risks of opioids as an important component of treating adolescence, and recognize that the basic principles of safe opioid prescribing pertain to adolescents as well as adults. In the presentation, we are going to talk about the following contents. First, some definitions, then the epidemiology of opioid use disorder in adolescents and children. Then we'll talk about some examples of the management of acute pain with opioids, and finally, chronic pain in adolescents with opioids. Now, first, some definitions. I think these are important to be laid out now so that we're all on the same page. So when we're discussing certain terms, you know what I'm talking about. Now, let's talk first about physical dependence. Dependence means the propensity to exhibit withdrawal symptoms with discontinuation of the substance. Now, dependence occurs for reasons typically because the receptors on cells, typically neuronal cells, downregulate in the presence of the drug. In other words, the receptors become less sensitive to the drug we're talking about, and therefore, it takes more of the drug to have the same effect. And in the absence of drug, physical dependence symptoms occur. We call those withdrawal symptoms. And they are generally the opposite of the substance's effect on the body. So that if a drug causes sedation, withdrawal will manifest as excitation. If the substance results in constipation, then withdrawal will manifest as diarrhea, et cetera. Now, while opioid use disorder is accompanied by dependence to opioids, generally 100% of the time, the presence of dependence does not imply that opioid use disorder is present. Let me say that again. The presence of dependence is not synonymous with the presence of OUD. For example, dependence occurs with many substances, caffeine, nicotine, catecholamines that are used to treat nasal congestion or asthma, and benzodiazepines. The fact that you have a headache in the morning without your coffee does not mean that you are dependent on the coffee. That is to say, you don't have caffeine use disorder. Okay? Now, physical tolerance. Physical tolerance means the need to take larger and larger doses of a substance, including opioids, in order to achieve the same pharmacologic effect. And tolerance is the other side of the coin of dependence. So in other words, dependence and tolerance almost always occur simultaneously. Tolerance typically occurs because, again, the receptor down-regulates, and it requires more and more presence of the substance that we're talking about, in this case opioids, to achieve the same effect. Dependence can also occur because the body learns how to better metabolize the substance, typically in the liver. So metabolism speeds up, blood levels decrease, and therefore it takes a larger dose to achieve a therapeutic blood level. Now, as before, opioid use disorder is virtually always accompanied by tolerance. But the presence of tolerance does not imply that opioid use disorder is present. For example, tolerance, again, occurs to many substances. It occurs with caffeine, insulin, catecholamines, cannabinoids, alcohol. If you are tolerant to alcohol, it may mean that you can have two or three glasses of wine instead of one glass of wine at dinner without becoming buzzed. That does not mean that you have alcohol use disorder. Now, there's often a lot of mixing up of the term opiates and opioids. So what are the differences between opiates and opioids? Opiates are chemicals that derive from the opium poppy. They act on the mu opioid receptors in the human body. So opiates are actually chemicals that are made from the opium poppy, and they include opium, obviously, heroin, morphine, oxycodone, hydrocodone, hydromorphine, and codeine, whereas opioids are chemicals that may or may not be derived from the opium poppy, but they act as opiates. That is to say, they're synthetic molecules that also act on the mu opioid receptors, producing the same effects as opiates. So it's just a small distinction. Opioids come from the plant. Opioids are made in a laboratory. They include, most commonly, fentanyl, but also meparidine, also known as Demerol, and methadone. Now, let's talk about opioid misuse. That is to say, not abuse, but misuse. Misuse is the use of opioids or any other drug differently than as prescribed by the provider. And that misuse goes on for different reasons, and regardless of possible known harm to the misuser. They include taking opioids when not prescribed, taking opioids more often than they were prescribed, taking larger doses than were prescribed, using leftover prescriptions of opioids for a subsequent painful event. That is to say, you have some oxycodone left over from when you had your wisdom teeth out, and you put it away for a future event, like when you sprain your ankle the next month. That is both using opioids when not prescribed, and obviously using opioids in a larger dose since they were not prescribed. That's misuse. The repeated episodes of opioid misuse, however, in teenagers particularly, can be concerning for the later development of opioid use disorder, and therefore should be evaluated and discouraged. And also can be a risk for unintentional opioid overdose, especially for youngsters in the family, toddlers, young children, who may discover those leftover pills in a mother's or grandmother's purse, or in the medicine chest, or in the kitchen drawer, and take them. So saving opioids for a future date is not a safe thing to do. So how is that distinguished from opioid use disorder? Now this is the definition of opioid use disorder, taken from the Diagnostic Manual, Edition Number 5, that's used in psychiatry for defining OUD. And it's a very wordy slide, and I'm not going to read every point, because I don't like to read slides. You have the slide available, hopefully before this presentation, for you to read. You can download it for later presentation. And of course, you can always pause this Zoom presentation, read the slide, and then come back to my voice. Here are the essential features of opioid use disorder. They are the persistent desire or unsuccessful effort to cut down on opioid use, spending a lot of time and activity trying to obtain opioids, very importantly, the craving for another opioid dose, the use of opioids despite harm, that is to say, resulting in failure to fulfill obligations at work, school, or home, the destruction of social connections, the using it in spite of the risk of incarceration, and the continued use of it despite knowledge of its danger. And then you can read the other points as well. It's not necessary to have to meet every one of these bullet points to be diagnosed with opioid use disorder. Now, OUD, like any other disorder or disease, can be categorized as mild, moderate, or severe. And it's important to know that opioid use disorder replaces the outdated term of opioid abuse. And it certainly replaces the term addiction. And I discourage you from using the word addiction unless you're talking amongst yourselves, perhaps because it is a useful shorthand abbreviation for the wordiness of opioid use disorder. But you should certainly steer away from using the word addiction when talking to clinicians who are not familiar with opioid use disorder, and especially when talking to patients and family. Because the word addiction is extremely pejorative and implies the desire to take these substances. And using the word OUD puts the condition into the category of illness and not choice. So in the medical setting, it's better not to use the word addiction. To put it another way, there is no human being who wakes up in the morning and says, today I think I'll become an addict. Nobody enters into the state of addiction with desire or voluntary behavior. It is a disease that people find themselves suffering from involuntarily. So I just broke my rule here with a second bullet point, saying addiction is a treatable chronic medical disease. OUD is a treatable chronic medical disease. And it involves a complex interaction of three elements that we'll talk about in just a moment. And it takes two of those elements, and sometimes all three, to develop OUD or addiction. And the word addiction is often used in normal behavior to describe normal behavior in everyday terms. And here's some examples. I used to be addicted to the television show Curb Your Enthusiasm. I'm a caffeine addict. So it's a term that shouldn't be clinically used. Now, the risks of opioid use disorder in youth are these. Now, addictionologists, geneticists, believe that as much as 60% or 70% of the vulnerability or liability to become addicted to opioid is genetically determined. Think about that for a second. Opioid use disorder is, largely speaking, a genetic disease. Again, it's not a disease of choice. It's a genetic disease. Just like nobody wakes up and says, I think today I want to be a diabetic, nobody wakes up and says, today I think I want to be a drug addict. There's a strong demilial orientation to becoming affected with opioid use disorder. And those data are very, very convincing and date back to studies that were done after the Vietnam War, where twins were studied, twin-twin studies, where if one twin who went to Vietnam became addicted to heroin, the odds were very high, 70%, that that individual's twin who didn't go to Vietnam and was still in the United States would also in their lifetime become addicted to heroin. So there's a strong genetic vulnerability, and the actual DNA patterns are now being worked out to define the genetic origin of that. Secondly, the second risk factor is exposure to the drug. Obviously, if you don't become exposed to opioids, you can never develop opioid use disorder. Children are born on a remote tropical island, and even if you have the genetic vulnerability, if you never see a molecule of heroin or oxycodone, obviously you will die never having experienced opioid use disorder. So that's an absolute requirement. The third element, which defines the risk of opioid use disorder, both in adults and in youth, is psychiatric disease. In youth, ACEs, Adverse Childhood Experiences, are a very strong trigger of opioid use disorder in individuals who have been exposed to opioids, and especially those who have a family history of drug or substance abuse. The most common ACE that leads to vulnerability for opioid use disorder in youth is a history of sexual abuse in childhood, and second to that is physical abuse in childhood. But other DSM-5 or psychiatric diagnoses associated with opioid use disorder are also personality disorders, particularly narcissism and borderline personality, depression, and PTSD. There you see the reason why so many veterans returning from war zones, most recently that would be Afghanistan and the Middle East, have such a high rate of opioid use disorder, and that is because of the high rate of PTSD. There's a strong tendency for those individuals who have these very unpleasant psychiatric diagnoses to self-medicate with opioids and other substances, including benzodiazepines, cannabinoids, and alcohol to treat, to tamp down the symptoms that they have of their psychiatric diagnoses. Male gender is a strong risk factor. It's much more common in males than in females. And also in youth, a history of academic failure, a history of other substance abuse, and of course, as I said, exposure to opioids, whether on the schoolyard, the street corner, or because of opioids that were taken from a medicine chest at a friend's house, or because of leftover opioids that have been used recreationally. All these are risk factors for the development of opioid use disorder in youth, and we'll come back to some of these in the clinical examples we'll talk about later in this morning's talk. Now, what are the signs of possible opioid use disorder? These are not diagnostic, but they're definitely red flag raisers. Frequent emergency room visits for pain, especially when those emergency visits are accompanied by requests for opioids, is a red flag. Maintaining pain medications illicitly, forging prescriptions, buying it on the street, stealing it from friends and families, is a big red flag for the development or the presence of opioid use disorder. Loss of control, as we've said, craving is a strong characteristic of OUD, and use despite harm. So we see individuals skipping school, failing school, destroying their social relationships with friends, family, et cetera. Those are all serious risk factors. Red flags. And, of course, tolerance, escalating dose requirements, administering medications other than by the oral route, snorting or injecting, obviously, very worrisome red flags, and combining opioids with other drugs, such as benzodiazepines and alcohol, particularly, to intensify their effect. So none of these are by themselves or even in combination diagnostic. You have to go back to the DSM-5 diagnostic criteria to define opioid use disorder. But these are certainly things that should raise a significant level of concern in teenagers. Now, having said all that about teenagers and opioid use disorder, which, of course, we think is epidemic in this country, let me try to put it into a little perspective and tap down the anxiety that the discussion of opioid use disorder generates. Now, we know that in 2023, the last year in which we have complete data, because I'm taping this in January 2025, and we only have data in 2024 going to October or November. So we're going to leave that year out and talk about 2023. There were over 100,000 drug overdose deaths in this country, of which opioids accounted for about 75%, about 81,000 deaths. That's a lot of deaths, right? A lot of people die from opioid overdoses. Now, most of those, the vast majority, 75%, of these opioid deaths were attributed to street fentanyl, not pharmaceutical opioids. So here in this discussion, in this lecture, we're really talking about prescribing opioids. And because opioid deaths are, in this era, this present era, largely attributed to fentanyl, accidental overdoses, not the medications that you prescribe, you should feel less anxious about prescribing those opioids, knowing that they're unlikely to result in significant complications such as death and overdose in the population of patients that you're treating. Now, having said that, as I said, 81,000 sounds like a lot of deaths, and it is a lot of deaths, but let's just compare it to other causes of preventable deaths in this country. Alcohol-related deaths are two and a half times more common than opioid deaths. So nearly 200,000 Americans die every year from alcohol, including acute intoxication, which equals the number of deaths from opioids. So we have 80,000 deaths from acute ingestion of opioids by one route or another, and we have the same number of deaths from alcohol intoxication, and yet we don't seem to have the same national and governmental concern for alcohol poisoning as we do from opioid poisoning. I'm going to let you ponder why that is sociologically and politically, but just know that opioid intoxication deaths are no more common than alcohol intoxication deaths. The rest of the deaths from alcohol are from liver disease and carcinomas, so alcohol deaths are very common, and if you think 170,000 deaths from alcohol is a lot per year, there's 300,000 deaths every year from tobacco, including cancers and peripheral vascular disease, etc. So if we take together alcohol and tobacco, we're talking about nearly half a million deaths a year that are completely and totally preventable. So the number of opioid deaths from opioid intoxication pales in comparison to these other two commonly-obtained substances that you can walk into any drugstore or grocery store and purchase without a prescription. So let's just think about that, ponder that for one second. Opioid deaths are a tragedy, and we need to do what we can to prevent them, but they're nowhere near as significant in terms of the population as these other two substances, alcohol and tobacco. And of the opioid deaths, a small minority are related to prescribed opioids, and an even smaller minority are related to the appropriate use of those prescribed opioids. So that should make us all feel a little bit more relaxed. I think about prescribing opioids and using them appropriately for pain management in our patients. Now, there is even better news than I just told you if you want to consider that good news, and that's that opioid overdose deaths are declining in the population we're talking about, children and adolescents. In fact, 2024 was on track for the lowest number of opioid deaths since opioid deaths were tracked for the first time in the 1970s. So opioid deaths in people under the age of 18 are really uncommon, and they're becoming less and less uncommon every year. So they went up around 2010 or so, and they've been on the decline since then and are on track for being a very, very uncommon event in adolescents in 2024 and hopefully in 2025. And adolescent misuse of opioids is declining as well. So only 1.6 of adolescents report using non-heroate opioid misuse in their lifetime. That is to say, at any point up to their present age. And it's the lowest prevalence of misuse of opioids since 1977, and eight times lower than about 20 years ago when we start dating the beginning of the opioid crisis or epidemic in this country. So it's very uncommon in adolescents, fortunately. So why are we talking about it? Because it's still a problem, and it's still occurring, and we need to be aware of it. But this slide shows you the decline in opioid misuse self-reported by 12th graders going back to the 1970s. You can see it's the lowest it's ever been, and that should be a reason for some encouragement. Now we talked about the three risk factors for the development of opioids. Opioid use disorder, that is to say, exposure, which we have some control over, a lot of control over, family history, and psychiatric disease. So we recommend this medical advice to teens and parents. Never use an opioid pain medication unless it's been prescribed by your clinician. Opioids have bad side effects, including unpleasant side effects like constipation and nausea, vomiting, itching, but serious side effects, such as loss of consciousness and deadly dangerously respiratory depression. Teenagers and adults, their adult parents need to know this. And also, they should be told that adolescence is a vulnerable time, a time when experimentation naturally occurs. That time period between 15 and 20 is a time period of experimentation and a sense of immortality. So teenagers think they can do whatever they want. They can ski down a hill fast without a helmet, they can drive their car fast, they can jump off of cliffs into water, and they can take opioids and smoke cannabis and do other things with impunity. But of course, we know there's no such thing as impunity, and this message needs to be communicated to them over and over again during routine medical visits and other medical visits as well. Here are the reasons that teens give for misusing opioids. It's easy to get from the medicine cabinet. We're not talking about the ones who were prescribed opioids for post-surgical pain or broken ankles or something, but we're talking about leftover medicine that they can find in the medicine chest at home or when they go to a friend's house. And they go to the bathroom and they riffle through the medicine chest, and lo and behold, there's a bottle of hydrocodone. Well, let's give it a try. It's available everywhere. It is available everywhere. It's available on the street, at school, in the medicine chest, in their friend's house. They perceive that it's not illegal, so if it's a prescribed substance, they think, oh, they're not breaking any laws when in fact they are. It's easy to get from other people's prescriptions, especially their best friends. They can always claim to have a prescription if they're caught by their school principal. It's cheap, and it is cheap. They think it's safer to use than other illegal drugs, but it's not, et cetera. So these are all teachable moments. When you're dealing with teenagers, you have an opportunity to dispel these myths that they have in their mind about why it might be okay to try some opioids. And the biggest reason of all is they may think that what they're getting for a few dollars on the street corner is a couple of tablets of oxycodone, but all too often what they're getting is a couple of tablets of oxycodone plus fentanyl, and that fentanyl is going to be potentially fatal. So the reason that teens are overdosing and dying from opioids is usually because of the accidental, unaware ingestion of fentanyl in what they think they're taking doesn't contain fentanyl. So the anticipatory guidance that you give teenagers is very, very important. Now remember that most opioid prescriptions are not written by primary care pediatricians. Who do you think prescribes opioids the most to teenagers? You might be surprised to learn that the number one prescriber of opioids to adolescents is dentists, which makes sense when you think of all the teenagers getting their third wisdom teeth, their third molars or wisdom teeth out. So as a primary care provider or somebody working in a primary care office, and maybe if you are a dentist yourself and you're listening to this lecture, you will take home the fact that it is a good idea to review the risk of opioid ingestion, either licit or illicit, with your teenage patients. Now secondly, it's always a good idea. In fact, it's always indicated, and I would say it's almost always mandatory, or it should be mandatory, that when an opioid goes home with a teenager, they also go home with a prescription or a bottle of naloxone Narcan nasal spray. I have many friends who have saved lives by having naloxone nasal spray at home and in their family vehicle. And it wasn't necessarily their own children. I can tell you I have a couple of colleagues who are anesthesiologists who have saved their own children with naloxone nasal spray, but many others have saved other teenagers or even strangers on the street by having naloxone nasal spray. And the naloxone nasal spray is not just useful for treating an overdose in your patient, but also the younger children in the family who may get into that bottle of prescribed opioids. Let's move on to the next slide and start talking about the management of pain. Opioids are powerful pain medications that have many side effects and a huge potential for misuse, diversion, and addiction. So why do we still use them? They can be used safely to treat pain, but why do we still use opioids? And the answer to that is that in 3,000 years of opioid abuse, dating back to the ancient Sumerians, no stronger analgesic has been discovered. All of us who treat pain routinely wish that we didn't need to prescribe opioids, that we had a safer alternative without the liabilities, but in fact, we don't. But there are things that we can do that will reduce the opioid requirement in severe pain. And if we are required to use smaller doses, if we need to use smaller doses, then we have introduced a greater margin of safety. And there are multi-drugs that can be used in concert with each other that will add their effect to each other that will, in fact, in cases of moderate pain, actually eliminate the need for opioids altogether. So we refer to this as multimodal therapy, and you know what most of these drugs are, but chances are you maybe have been using them one at a time. But modern analgesic practice in pain management programs now use all of these drugs or most of these drugs altogether. Now there are non-pharmacologic methods, which are useful to a certain degree, and there are pharmacologic methods. The non-pharmacologic methods include using heat, local heat to an injury, ice, compression of a swollen part of the body, splinting of a fracture, and physical therapy and biofeedback, especially the latter two for chronic pain. Non-opioid pain medications, pharmacologic methods include the use of non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, meloxicam, acetaminophen, also of course known as Tylenol, which is a vastly underrated analgesic, celecoxib or Celebrex, and gabapentinoid molecules such as gabapentin, and Lyrica or pregabalin. And of course, if you need guidance in choosing these medications, in dosing these medications, and knowing how to stop these medications, then it's always a good idea to seek guidance from a pain specialist if needed. And in treating pain, it's always important to look for underlying mental health disorders that may be complicating your treatment of pain, especially chronic pain, because we all know, and probably have had the personal experience, that anxiety and depression and in fact, insomnia, amplify the sensation of pain. I also want to point out that in the treatment of acute pain and chronic pain, in fact, it's important to know that there are biases that we all bring to the table in the prescription of opioid for pain, especially for minority groups, and particularly for African-Americans and Latinos. Now, that's because a strong cognitive and cultural bias has been discovered in prescribing these substances. There's a lot of mythology that African-Americans are particularly prone to opioid addiction. They're not. In fact, white patients are seven times more prone to developing opioid use disorder than black patients are, which is probably something you didn't know. Similarly, male prescribers often fail to acknowledge or underestimate pain in female patients and under-prescribe to those female patients. That's very common, particularly if the female patient is reporting pelvic pain. And as I told you, that opioid use disorder and deaths are more common in white people per capita than they are in minority populations, including blacks and Latinos. So therefore, it's important to be aware of these biases when you're prescribing. Now, in the pediatric setting, acute pain is way more common than chronic pain. The hallmark of acute pain is that it's time limited. You have appendicitis, a broken ankle, wisdom teeth removal. It's going to hurt, but it's only going to hurt for a matter of days or maybe weeks, and then it's over. So you probably know that opioids are not going to be used for minor trauma, for common musculoskeletal pain, like a sprained ankle, for headaches, abdominal pain. Actually, I should tell you that there is a disappointingly high frequency of the management of headaches in emergency rooms with opioids, which is almost always inappropriate, dysmenorrhea, things of that sort. And many of these things, in fact, respond better to non-steroidal anti-inflammatory drugs and Celebrex than they do, or Celecoxib, I should say, than they do to opioids. It's clear now that wisdom tooth extraction pain or other dental extraction pain is way more sensitive to non-steroidal inflammatory drugs than it is to opioids, and dentists are finally beginning to understand that and not prescribing oxycodone or hydrocodone for their wisdom tooth patients. We all know that, I hope that, especially after the last slide, that if you maximize use with multimodal therapy, you will minimize the use of opioids. And you should always, of course, discuss the side effects and risks of opioids. I'm going to repeat that, which I've said before. You're going to discuss risks and side effects with the patient and with the patient's guardian or parents, and monitor them while they're taking their opioids. And advise them, importantly, to dispose of leftover opioids. Now, in the remaining time, let's talk about a few specific examples. And in the last example, we'll talk a little bit about the specific modalities that are useful in treating chronic pain in adolescents, which, fortunately, is not common. So the first example is a patient whose name is Mark, and he's a 17-year-old. You've known him in your practice, in the family medicine clinic, since he was an infant. And he's healthy. He hasn't had anything happen to him recently or in the past. But he inverted his ankle during football practice, and now he's in your office complaining of tenderness in the right ankle and swelling. His range of motion is normal, and there's no point tenderness to suggest a fracture. And in fact, you order an X-ray, and it shows there's soft tissue swelling, but there is no fracture. So what do you do? You advise him to use RICE therapy, which is an acronym, R-I-C-E, which stands for Rest Ice Compression with an A-SRAP, and Elevation. And you tell him he can weight bear as much as he can tolerate, but no physical education, no football practice, no running, tackling, et cetera, for the next week at least. And you give him a pair of crutches and teach him how to use them. You give him ibuprofen to use, Tylenol to use every six hours for pain. The Tylenol should actually be used every six hours, not PRN, ideally. And he can add ibuprofen to that on a PRN basis. But Mark says he's in a lot of pain, and he wants an opioid. He wants oxycodone. So what are you going to do? Now first of all, a request for an opioid in a teenager, especially in an acute situation like this, is concerning, and it brings up questions. Is the pain really intolerable? Is he seeking opioids for another reason? The request for a specific opioid, when he says, hey, can you give me oxycodone, that's particularly concerning. How does he know the word oxycodone? Most teenagers don't. Does the patient want to use opioids for a quick fix? What's going on here? So you need to gather more history to try to understand the motivation for that question. Well, it turns out that at a recent health maintenance visit, he actually, during a screening, did report he was using alcohol once or twice in the past year, but no other substance. And you gave him advice to stop drinking. Well, that's not unusual. That's not even worrisome for a 17-year-old high school senior. Most of them are going to have experience drinking alcohol at parties or at football games. When you ask him to rate his pain as he's sitting in your office, he says, oh, it's 2 or 3 out of 10. But when he stands on his leg, it's 8 or 10 out of 10 in pain. Well, of course it is. That's normal. That's why you told him to use crutches and avoid weight-bearing for the next week until that sprain can heal. You don't need to have oxycodone instead of crutches. That doesn't make sense. And then he says what the real issue is that there's a big game on Saturday, today's Monday. He does not want to miss that game. And he figures with pain medication, he can play. So here is a good teachable moment. He falls into the category of adolescents who think that it's a quick fix and other guys on the football team have told him that oxycodone worked for them. So he asked for oxycodone and you have some guidance for him. You need to say, yeah, it hurts. I know it hurts. Acknowledge the pain, establish trust. Don't minimize it. Tell him, yeah, it does hurt. You know, it really hurts. Make a plan with him, a schedule for him for pain control, you know, in terms of using ice, taking Tylenol around the clock, which obviously he has not tried yet because he's just come from practice to your office. And tell him that non-weight-bearing and ice and compression will actually heal his sprain faster than walking on it and continuing to re-injure it. Give him realistic expectations. Tell him how long it's going to take to stop hurting. Involve his parents in the discussion. Make sure they know that he's out of athletics for a week. Maybe give him a little source of fear. You tell him that if he doesn't take a week or two off from athletics, he'll be taking the rest of the season off of athletics because he's going to make his injury worse. And then follow him closely. Offer to see him back in the office by the end of the week and see how he's doing. Here's another patient. Ben is an 18-year-old male, and he has a family history of alcohol abuse, alcohol use disorder. He recently completed a two-week alcohol residential treatment himself for moderate alcohol use. And Ben is in early remission. That is to say he has successfully abstained from alcohol use, but only for a few weeks, not for very long. But unfortunately, about a week ago, he fractured his tibia and fibula skein. It's a common ski injury. And boy, let me tell you, a tibia fracture is about as painful a fracture as you can have. And there's actually a suspicion that his parents' voice, that maybe it was used to, you know, his accident occurred because of alcohol use during the lunch break. He had a couple of beers with his chili in the lodge, something many of us may have done. And you know, you ski looser after lunch when you've had a couple of beers. And he was a little careless, and he skied into an object. Well, he underwent open reduction and fixation of the fracture. That means the surgeon had to open up his leg and put plates and screws in the tibia to fix it, and then sew it all up. So now he has a serious reason for having pain. He was discharged with a prescription for oxycodone and told to take one or two tablets every six hours as needed. And today is his first day without any medication, because he's used it every six hours for the last eight days. And he is in significant pain. He's going to see his orthopedic surgeon in two days. Now his history from the parents show that he's used the medication as prescribed, and the pill count shows that he's been using it as prescribed, which is to say they bring in an empty bottle. And he wants a refill of the pain medication. Does this sound reasonable to you? What is going on here? It's not an unusual situation. If you take a moderate dose of opioids, 10 milligrams four times a day for seven consecutive days, you may well develop a degree of tolerance to the opioids as well as physical dependence. And that means if you abruptly discontinue the medication because your pill bottle is now empty, you're going to produce symptoms of withdrawal. And remember, the symptoms of withdrawal are the opposite of this effect of the drugs. Opioids, oxycodone, cause analgesia. Withdrawal exacerbates pain. So the pain is even worse than it would have been without the opioids. And opioids are somewhat calming, and opioid withdrawal leads to anxiety. That, in my mind, is probably what's going on here. In my clinical situation at the Children's Hospital and in the clinic, we assume that 5 to 7 days of taking opioids around the clock is sufficient to produce a degree of opioid tolerance and physical dependence. And that means that rather than stopping the opioids abruptly, we will wean them over a period of a couple of days. And that weaning process allows a time period for the withdrawal symptoms and the tolerance to resolve, and then the medication can be stopped. So before prescribing for untreated pain, you would, of course, in his situations, always think about his prior alcohol use and whether this represents other things going on, such as early opioid misuse or abuse. And so you'll take into consideration excuses like he dropped the bottle in the toilet or something like that. But in the absence of red flags, in this situation, I think opioids should be re-prescribed once you've confirmed that, in fact, he has untreated pain. But importantly, you will prescribe them for a defined period of time. With dose tapering at the end of the prescribed period of time, you will give him specific instructions on how to taper the opioid dose. And very importantly, you will communicate this with his orthopedic surgeon for a couple of reasons. Number one, you don't want him to go back to his orthopedic surgeon in a couple of days and have the orthopedic surgeon not know that you prescribed the opioids. And he will then re-prescribe more opioids, and the patient will wind up with more opioids than they need. And that will be a problem, obviously. Secondly, you will describe to the orthopedic surgeon why you're re-prescribing and why you're tapering. And hopefully, this will be a lesson for the orthopedic surgeon to know that, in fact, a short period of tapering at the end of a prescription is a good idea. So Ben does have an obvious source of pain. You don't expect the pain from an open fracture site to resolve in a period of five or seven days. He has ongoing pain. And in spite of his history of substance abuse, that is to say, alcohol abuse, he can be safely prescribed opioid, especially with good monitoring. What does that mean? That means that you want to re-evaluate him in a relatively short period of time. You also want to think about, in the office, whether his pain is not coming from the fracture per se, but it's coming from an alternative problem, which is also not unheard of, especially in the setting of a two-fracture, tip-fip fracture of the foreleg, such as compartment syndrome, deep vein thrombosis, that may be causing persistent pain. And obviously, if you have any concern about that, you want to send them right away to his surgeon's office to have those ruled out. And then you will maximize non-pharmacologic therapy, multimodal therapy, if that has not already been done. And it probably hasn't, because I think the surgeon probably didn't start those things. You will consult your state prescription registry, your PDMP, to make sure that there's no other opioid prescriptions that he's been given in the last seven or eight days. You will set expectations for pain and recovery. And then you'll re-prescribe the opioids. In coordination with the surgeon, with discussion of side effects and risk, with counseling against using alcohol while he's taking the opioids, you'll make sure the parents have control of the opioids. They're locked away and dispensed by the parents. As I said before, he'll go home with nasal naloxone for emergency use by his parents. And you'll have a prescription agreement with the family and the parent that says that you will be the only prescriber. He will not get early refills for any reason at all. And the parents will monitor him carefully. Now, here's a third example of acute pain. Moving along the spectrum of patients, Kayla's a 16-year-old, and you saw her once in your practice years ago for routine health maintenance. And she's been lost to your practice since then. But here she is again, presenting with an urgent appointment because her finger was slammed in a door. And she reports severe, diffused pain. But on exam, there's really not much to see. There's no redness and swelling. And the range of motion appears to be somewhat limited by pain. And so you think this is a soft tissue injury, and you recommend ice, splinting of the finger by body taping it to the next adjacent finger or splinting it, and non-steroidal anti-inflammatory drugs as needed. But in spite of the physical examination findings, she says the pain is unbearable and asks for pain medication. Now here's an example of a patient presenting with pain reported out of proportion to the mechanism of injury and to your physical examination. And that always prompts concern for opioid seeking and should prompt additional seeking of information by you. Now the absence of being in the clinic for six years and sudden reappearance is always a red flag, especially when it's predicated by a minor event, which ordinarily would go to an urgent care center, and it raises concerns. So here is an opportunity for patient education and a different kind of an intervention. So you screen her. You screen her using a drug screening tool, such as the SBIRT now, which is recommended for adolescents to assess unhealthy habits. And because of her long absence from the clinic, you're going to do more history taking. You tell her that you always ask kids these questions. It's not that she's not trustworthy, and you do that before prescribing medication. So she actually reports that she uses alcohol and cannabis regularly. Monthly, she says, which probably means more than monthly. She reports that she's used pain medications once or twice in the past year, recreationally. And she says that when she was doing that, she was experimenting with friends, but she stopped because one of her friends overdosed, and that scared everybody. So now here you have a child with a history of alcohol use, cannabis use, recreational opioid use, even if it's not continued, according to her. Teen experimentation. In other words, she doesn't meet the criteria for OUD, but she has concerning signs for possible OUD now or in the future. Use of multiple substances, disproportionate pain, new to your practice, compulsive use of opioids, compulsive request of opioids, et cetera. And so these are red flags. And so your suggestion here will be to acknowledge the pain. Yeah, it really hurts. Slamming a door finger in a door hurts. But opioids are not used for this kind of pain. You're more concerned about her use of opioids in the past, recreationally, as well as other substances. You're going to teach her and her parents that opioid use disorder occurs in kids as well as in adults, even after just using opioids a couple of times, especially if they have the vulnerability from genetics. And you're concerned that this may be a problem. You don't prescribe opioids. You do prescribe naloxone, not knowing if she has them at home. And you suggest that perhaps that she needs to see, to the parents, you suggest that she may need to see somebody who's experienced in treating addiction and opioid use disorder or other substance use disorder in a mental health clinic. Now, finally, we'll conclude the discussion today with a brief discussion of managing chronic pain, which is something which does occur in children, but it's not very frequent. In the course of a child's childhood, in a patient's childhood, about 10% will experience chronic pain, which is defined by either constant or recurrent pain of greater than three months duration. It's not always serious, severe pain, but it is pain nonetheless. And it's also typically not associated with an underlying somatic pathology, while acute pain is always associated with something, surgery, injury, burn, illness. In chronic pain, the initial triggering event, illness, injury, surgery, burn, et cetera, may have occurred months ago and is completely resolved, but the pain persists to the present time. So the inability to define an underlying, ongoing pathological process does not rule out the presence of chronic pain. It's important to understand that with some exceptions, opioids are very infrequently used in the management of chronic pain in pediatric pain clinics. The exceptions to these would be the kind of severe chronic pain that would be associated with malignancies, terminal cancer pain, end of life pain, but generally, multidisciplinary and multimodal approaches to chronic pain are the most effective and associated with the most success. So when possible, referral and co-management with a pediatric pain management center is advisable if you have one in your geographic area. So let's talk about a case of Lisa, who's a 16-year-old athlete, but she has spondylolisis. That is to say, she has movement of one vertebral body over the other, slippage of a vertebral body, causing chronic back pain. And it was adequately managed for a while with nonsteroidal anti-inflammatory drugs, but now those are failing. She's wearing a back brace, and that's, to some extent, helpful. And her orthopedic spine surgeon is planning surgery in about six months to correct this. He prescribed opioids about three weeks ago because of her persistent complaints of pain associated with her back pathology. And now you're seeing her routinely, and she's reporting having difficulty despite the opioid medication. Now here, our patient has a source of pain. It's not responding to non-opioid therapy, and it's not even responding to opioid therapy. So what could be going on? Well, we might consider the fact that the opioids are underdosed, that she has progression of her pathology. She may have the development of an alternative pathology that's related to her spondylolisis, spinal nerve root impingement or compression, that is to say, neuropathic pain. There may be depression. Here we have an athlete who can no longer compete, who may not ever be able to compete athletically in the future after her spine operation. That's very depressing for most teenagers, and most adults for that matter. She may be seeking relief from that. She may be self-medicating for this depression with a substance such as opioids. And that would be a risk factor for development of substance use disorder, as we talked about previously. And so you have a discussion with Lisa. You find that she's been missing a lot of school lately. She spends most of her days reclining in bed or on the couch. She's being tutored at home. She's lost her social connections, except that she maintains them to some extent online. And she watches a lot of movies, a lot of Netflix, and that helps her to make herself feel better. And she denies the past use of tobacco, alcohol, et cetera. So those risk factors are absent. But she's never misused or sold or shared her prescription. In fact, she says, her mother keeps the prescription locked away and only gives it to her once a day because the mother's concerned about the risk of opioids. OK. Well, you confirm all of these facts with her mother, which is important in a second discussion. She confirms that she does not believe that Lisa uses tobacco, et cetera. And she confirms that she only gives opioids about once a day because she has heard there were addictive, and she's worried about that. And she has an uncle with a substance use disorder. And she also thinks that she, in fact, may be depressed. So here we have a patient with chronic pain who's undertreated for pain with opioids. Once a day opioids are probably not going to cut it for severe orthopedic spine pain in an adolescent. This results in Lisa clock watching for pain. She watches the clock to see when she can get her next scheduled dose. And in fact, she probably has a bit of a mood disorder, which exacerbates the intensity of the pain. So you acknowledge the concerns her mother has about opioids, but you emphasize the fact that opioids can be used safely and should be used with monitoring, which relieves and mitigates those risks. You recommend that they have naloxone available in the household in case there is an overdose. You give her mother and Lisa an overview of opioids and explain how useful they are. You screen her for depression. You recommend multimodal therapy should be started, which hasn't been used in the past. She's used NSAIDs, but she hasn't used other things, such as an antidepressant, which is useful for the treatment of chronic pain, as well as, of course, improving mood and improving sleep. Ice and heat, physical therapy, getting her out of bed and moving is definitely going to be useful for her pain. Sitting and laying all day long is not going to be useful because she'll develop core muscle weakness, which will exacerbate the pain. And you recommend ongoing opioid prescriptions, which should be coordinated with their orthopedic surgeon to prevent double prescribing. You work out with the orthopedic surgeon who will be prescribing the opioids, and you monitor the PDMP on a monthly basis to make sure that there's not overlapping opioid prescriptions. And you ask her to return for a week to see how these things are working, and she does. And the report is, in fact, the medications are helping, she feels better, and she's starting to see a mental health professional to alleviate her anxiety and depression. All right. We mentioned in an earlier patient that it's a good idea to have an opioid use agreement. We used to call those opioid contracts with patients and families. And it's something that is useful for chronic administration of opioids. The opioid use contract is one in which the patient and the parent agree that there's only one prescribing physician or advanced practice nurse or dentist or clinic, and only one pharmacy. That prevents overlapping prescriptions and a pharmacist that is unaware that other pharmacies are prescribing. Therefore, there should be regular checks of the state PDMP to confirm that no other prescriptions are going to the patient, as well as no other controlled substances that may adversely interact with the opioid. There should be no early refills for lost or stolen prescriptions. You'll hear all kinds of excuses about this. The dog ate them, the toilet, you know, got dropped in the toilet, got lost, was stolen by a friend. All of these things will not result in early refills. There'll be no dose changing without permission from the prescribing physician. If you're the prescribing physician, no dose changing because the orthopedic surgeon says, oh yeah, you should take more. All unused medications are brought in for pill counts at every visit. The parent controls and dispenses and supervises the taking of the opioids at all times. This prevents opioid hoarding and multiple dosing by the patient in the absence of the parent. And they agree to report symptoms and side effects and all emergency room visits promptly and honestly to the practice. Well, the prescriber will coordinate prescribing with other physicians, not issue early refills, check the PDMP, et cetera. And remember what I told you earlier about tapering the opioids rather than abruptly discontinuing the medications because discontinuation will lead to withdrawal symptoms. And that's especially important in a patient like this who will be taking opioids perhaps for six months until the surgery occurs, then the opioids are prescribed post-operatively. And that's the situation in which you don't want to stop the full prescription immediately post-operatively. Now, distinguishing pain from opioid use disorder, inadequate pain management versus opioid use disorder, with pain management without misuse, usually function improves. And with opioid use disorder, function declines in spite of the use of opioids. Opioid side effects are bothersome to patients who are using them appropriately. But opioid use disorder patients usually minimize or deny side effects. Doses are easy to stabilize with the patient who has pain, but opioid doses are frequently requested to be increased in patients with opioid use disorder. And of course, we talked about leftover medication versus requests for early refills. So in summary, in the pain patient, both acute and chronic, non-opioid therapy should always be used whenever possible and whenever effective. Multimodal pain management is more effective than single-agent management. Patient and family education about the risk of opioids is an important component for treating adolescents. It's important to all patients. And of course, all the principles that you've seen in other of these lectures about adult prescribing practices apply to adolescents as well. Remember that adolescents up until the age of 25 or so have poor executive function and engage in risky behavior, especially males. And this puts them at risk for poor decision-making, peer pressure influence, and impulsivity that makes them higher at risk for opioid complications, misuse, and morbidity and mortality. So the references are on the slides that you can download or you already have downloaded. And I just want to tell you about a couple of final things before we conclude. The PCSS MOUD mentor program is designed for you to offer general information to you about clinical practices that are evidence-based in prescribing medications for opioid use disorder. The mentors are a national network of providers with expertise in addictions, pain, and evidence-based treatment, including medications for opioid use disorder. And there's a three-tiered approach that allows every mentor-mentee relationship to be unique and catered to your specific needs. And these are provided at no cost to you. If you have a clinical question, ask a colleague is a simple and direct way to receive an answer. And the website is below. You probably already have it for a discussion forum in which you will have an opportunity to ask colleagues questions, to receive answers related to medications for opioid use disorder, and to receive prompt responses to practice-related questions. So with that, I will conclude. These are the collaborators that comprise the provider's clinical support system. And the mantra of PCSS is educate, train, and mentor. Finally, again, here are the websites for the organization, the social media tags for the association. We encourage you to post on these websites, on these media sites, social media sites, to encourage others to take advantage of these resources. So thank you very much for your attention.

opioid use disorder

adolescents

opioid prescribing

opiate vs opioid

genetic predisposition

opioid misuse

naloxone distribution

pain management

non-pharmacologic interventions

mental health