Outpatient Prescription Opioid Use in Pediatric Medicaid Enrollees With Special Health Care Needs

Abstract

BACKGROUND AND OBJECTIVES: Although potentially dangerous, little is known about outpatient opioid exposure (OE) in children and youth with special health care needs (CYSHCN). We assessed the prevalence and types of OE and the diagnoses and health care encounters proximal to OE in CYSHCN. METHODS: This is a retrospective cohort study of 2 597 987 CYSHCN aged 0-to-18 years from 11 states, continuously enrolled in Medicaid in 2016, with $1 chronic condition. OE included any filled prescription (single or multiple) for opioids. Health care encounters were assessed within 7 days before and 7 and 30 days after OE. RESULTS: Among CYSHCN, 7.4% had OE. CYSHCN with OE versus without OE were older (ages 10-18 years: 69.4% vs 47.7%), had more chronic conditions ($3 conditions: 49.1% vs 30.6%), and had more polypharmacy ($5 other medication classes: 54.7% vs 31.2%), P , .001 for all. Most (76.7%) OEs were single fills with a median duration of 4 days (interquartile range: 3-6). The most common OEs were acetaminophen-hydrocodone (47.5%), acetaminophen-codeine (21.5%), and oxycodone (9.5%). Emergency department visits preceded 28.8% of OEs, followed by outpatient surgery (28.8%) and outpatient specialty care (19.1%). Most OEs were preceded by a diagnosis of infection (25.9%) or injury (22.3%). Only 35.1% and 62.2% of OEs were associated with follow-up visits within 7 and 30 days, respectively. CONCLUSIONS: OE in CYSHCN is common, especially with multiple chronic conditions and polypharmacy. In subsequent studies, researchers should examine the appropriateness of opioid prescribing, particularly in emergency departments, as well as assess for drug interactions with chronic medications and reasons for insufficient follow-up. WHAT'S KNOWN ON THIS SUBJECT: Outpatient prescription opioid use in children is associated with harmful consequences, including increased emergency department visits and critical care hospitalizations. Children and youth with special health care needs (CYSHCN) frequently use medications, yet little is known about their use of opioids. WHAT THIS STUDY ADDS: Approximately 7% of all CYSHCN and 14% of CYSHCN with a complex chronic condition received $1 opioid annually in the outpatient setting. Only 35% and 62% of opioid exposures were associated with follow-up visits within 7 and 30 days, respectively.

Children And The Opioid Epidemic: Age-Stratified Exposures And Harms

“…6 The increased prevalence of opioid exposures among youth with chronic conditions (for example, cancer and sickle cell anemia) may reflect opioids being appropriately prescribed, as previously reported. 9 Our findings that Black and urban children were less likely than their counterparts to fill opioid prescriptions or experience adverse events, but more likely to experience other opioid-related harms (for example, abuse and dependence), increase the call for future studies to explore racial and geographic opioid-related inequities in children. 3,7,8,13 We identified preceding opioid prescription fills in almost 50 percent of adverse events, which may suggest a temporal relationship between children's own prescriptions and subsequent harms.…”

“…Chronic disease status was defined according to complex chronic conditions methodology among children with six months of continuous enrollment. 9 The prevalence of opioid exposures and harms for children ages 1-17 was calculated using midyear enrollment as the denominator, presented for 2016-18. For index harms (that is, without a harm in the previous six months) in children ages 6-17, the most recent opioid prescription fill was identified in the six months before diagnosis; results for children ages 1-5 were not reported because of small cell sizes.…”

“…6 Disparities in pediatric opioid exposures and opioid-related harms have been reported by age, race, urban/ rural status, and medical complexity. 3,[6][7][8][9] In this study, we characterize age-stratified opioid exposures, opioid-related harms, and disparities for North Carolina Medicaid-insured children. As shown in exhibit 1, we found that the yearly prevalence of exposures and harms among children was highest among older adolescents, with one in ten (10.8 percent) adolescents ages 15-17 filling at least one opioid…”

Parent-Reported Symptoms and Medications Used Among Children With Severe Neurological Impairment

“…37 For example, pain was a highly prevalent reported symptom in this study, affecting more than half of all patients, and adequate treatment should be a high clinical priority. 4,5 Of the 39.0% of those reported to have pain but not using any analgesic, this may represent an underrecognized symptom. Of the 61.0% of those reported to have pain but already taking an analgesic, this may indicate undertreatment of pain, particularly when pain is occurring during normal state of health or better.…”

“…1 To help these children thrive, clinicians often prescribe multiple medications to treat a variety of problematic and interrelated symptoms, including pain, uncontrolled muscle tone, seizure, sympathetic storming, dyspnea, gastroesophageal reflux, and constipation. [3][4][5][6][7][8][9][10] Simultaneously, polypharmacy is associated with major morbidity and cost; however, our ability to recognize, monitor, and manage both desired and adverse symptoms associated with specific medications in the context of polypharmacy is severely underdeveloped. 8,[11][12][13] Children with SNI frequently have substantial communication impairment, further limiting clinical assessment of symptoms and evaluation of responses to therapies.…”