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Primary Care Corner with Geoffrey Modest MD: Prescribed Opioids and Future Prescription Opioid Misuse in Teens

10 Nov, 15 | by EBM

By Dr. Geoffrey Modest

Given the increasingly concerning issue of prescription opioid misuse, there was a disturbing article in Pediatrics finding that even appropriate use of prescription opiates in teenagers is associated with future opioid misuse (see  DOI: 10.1542/peds.2015-1364).

Details:

  • Prospective data from nationally representative cohorts of 6,220 12th-graders, followed up through age 23, in the Monitoring the Future study.
  • Initial survey data included questions on “legitimate” use of opioids, to see if the teens had ever taken narcotics because “a doctor told you to use them”, as well as use of marijuana/cigarettes/non-medically prescribed opiates/barbituates/alcohol, whether they disapproved regular use of marijuana, and some demographic and school performance questions. They also asked if in the last 12 months they had on one or more occasions taken “narcotics other than heroin on your own — that is, without a doctor telling you to take them”, followed by a list of brand-named and generic opiate pills, as well as questions about why they were taken (“to relax or relieve tension” or “to feel good or get high”)

Results:

  • Legitimate opioid use by grade 12 significantly predicted future opioid misuse later (increased 33%), 69% of the teens doing so to feel good/get high, or relax/relieve tensions.
  • This association was particularly strong in those 12th graders who are “least expected to misuse opioids”, including those who had disapproved or strongly disapproved of regular marijuana use and those without a history of baseline drug misuse. Teens in some of the lowest predicted risk strata for future opioid misuse (in the 1.75-3% probability) had a 3-fold increased opioid misuse if they had MD opiate prescriptions by 12th grade. Those in the 3-5% probability stratum had a doubling of opioid misuse later. There was no significant association of opioid misuse after being given legitimate opioid prescriptions in either the lowest risk group (0-1.75%) or in any of the groups with >5% risk. [For those unaware: the lowest risk stratum in this study was largely comprised of minority teens, which mirrors some other studies finding lower prevalence of opioid misuse among minority adolescents].

So, pretty impressive but observational study. Clearly there are a complex array of psychosocial factors involved in opioid misuse. But this study raises the question of whether us guys giving opioids to kids increases that risk. One reasonable inference from this study is that we should minimize giving opioid prescriptions to the most absolutely needy indications and at the lowest possible dose. In many cases NSAIDs or acetaminophen will suffice (e.g. studies show that NSAIDs work pretty much as well as opiates for kidney stone pain, reputedly one of the most severe pains).

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