Long-term Opioid Pain Treatment More Common in Youths With Mental Health Problems
By Will Boggs MD
NEW YORK—Adolescents with mental health conditions are more likely than their peers to receive long-term opioid analgesic therapy, according to a database study.
"There is a clear need for assessment of mental health conditions and related treatments, especially among adolescents being prescribed opioids,” Dr. Patrick D. Quinn from Indiana University, in Bloomington, told Reuters Health by email. “This could help inform pain treatment as well as whether additional mental health interventions would be important.”
Dr. Quinn's team previously found that rates of long-term opioid therapy (LTOT) were increased among patients, including adolescents and young adults, with mental health conditions and treatments.
In their current study, online March 12 in JAMA Pediatrics, they used data from the 2003-2014 Truven Health MarketScan Commercial Claims and Encounters databases to examine opioid receipt and subsequent transition to LTOT among adolescents aged 14 to 18 years with or without pre-existing mental health conditions and their treatments.
Adolescents with most prior mental health conditions and treatments were significantly more likely than adolescents without such conditions or treatments to receive opioids. For youths with bipolar or other mood disorder, for example, the odds were 17% higher; for any diagnosis treated with psychotherapy, they were 41% higher; for anxiety treatment with benzodiazepines, they were 63% higher; and for nonbenzodiazepine hypnotic treatment, they were 69% higher.
Although the cumulative incidence of LTOT after first opioid receipt was only 1.1 per 1,000 recipients within one year, increasing to 16.1 per 1,000 recipients within 10 years, all mental health conditions and treatments were associated with significantly higher rates of transitioning from a first opioid prescription to long-term therapy.
Relative increases in the rate of LTOT ranged from 1.73-fold for attention deficit/hyperactivity disorder to 3.88-fold for benzodiazepines, 4.02-fold for non-opioid substance use disorders, 6.15-fold for nonbenzodiazepine hypnotics and 8.9-fold for opioid use disorder.
“Long-term opioid therapy was relatively rare among adolescents,” Dr. Quinn said. “Out of every 1,000 adolescents who filled an initial opioid prescription, an estimated 3 transitioned to long-term opioid therapy within 3 years. But, we found that adolescents initiating opioid receipt who had a wide range of previously diagnosed mental health conditions were much more likely to transition to long-term opioid therapy relative to adolescents without those conditions. This pattern is similar to what we have seen in previous research on adults.”
“This study cannot tell us whether these adolescents should be prescribed opioids or long-term opioid therapy,” he said. “Answering that question requires evidence regarding the benefits and possible harms that come with those treatments.”
"Given the limited support for the efficacy of opioid therapy for chronic pain among youths, research is needed to understand potential adverse effects of LTOT among adolescents as well as the role that preexisting mental health conditions may play in harmful outcomes,” the researchers note.
Dr. Michael J. Mason from the University of Tennessee, in Knoxville, who wrote a linked editorial, told Reuters Health by email, "There is certainly a place for prescribed opioids when treating adolescents for pain as long as the American Academy of Pediatrics recommendations are carefully followed. Further, working directly with parents to develop an ongoing safety, monitoring, and communication plan is important.”
“I would hope that the healthcare culture in which physicians practice would allow the routine screening to identify risk factors,” he said. “Given the opportunity to conduct these screenings, I would hope that physicians would receive evidence-based training in screening, brief intervention, and appropriate referral.”
“This issue is complex and cannot be solved by physicians alone,” Dr. Mason said. “The health care culture needs to provide opportunities for a more comprehensive approach that includes preventative care. Evidence-based treatment needs to be available for those identified, many of which will have both a substance use and psychiatric disorder. Finally, there needs to be a simplified, user-friendly tool for parents to identify the risk level of their child and to have accessible evidence-based care that matches the level of the said risk.”
Dr. Kao-Ping Chua from the University of Michigan, in Ann Arbor, who has written about opioid prescribing to children after tonsillectomy/adenoidectomy, told Reuters Health by email, "Given the harms of opioid exposure in childhood, both in the short-term and in the long-term as adults, clinicians should reserve opioids for patients in whom alternative pain management strategies such as ibuprofen and acetaminophen are inadequate to control pain. This rule should hold whether a child has a mental health condition or not.”
“Results of this study suggest that ‘presence of a mental health condition’ could be a useful heuristic for clinicians who are seeking to determine which patients require heightened anticipatory guidance and follow-up when opioids are prescribed,” he said.
“This study should not be interpreted as justification to withhold opioids from children with mental health conditions when these agents are needed to control severe acute pain,” added Dr. Ping, who was not involved in the research. “That said, it is important to ensure that opioids are in fact absolutely needed before prescribing them to adolescents, particularly when they have risk factors for long-term use such as mental health conditions.”
JAMA Pediatr 2018.
(c) Copyright Thomson Reuters 2018. Click For Restrictions - http://about.reuters.com/fulllegal.asp