A Guide to Managing Opioid Use Disorder for the Pediatric-Focused APRN

There are many medication-based treatment options available for the management of neonatal abstinence syndrome and pediatric opioid use disorder, according to a session at the virtual National Association of Pediatric Nurse Practitioners 2020 Annual Meeting.

Kristin Hittle Gigli, PhD, RN, CPNP-AC, CCRN, a post-doctoral scholar in the Department of Critical Care Medicine at the University of Pittsburgh led the discussion with the latest data on pediatric opioid mortality.

There was a 268% increase in pediatric opioid mortality in the United States from 1999-2016, with 80% being unintentional deaths and 73% attributed to prescription opioids. In regard to the 1/3 of adolescents who died of co-ingestion, Gigli added that the most common co-ingestions are benzodiazepine and cocaine.

“Only about 6% of adolescents who die of an opioid overdose also had alcohol in their system at the time of their death,” Gigli said.

For opioid use in pain management, there is a particularly significant pattern in pediatric patients, trauma, and mechanical ventilation, according to Gigli. Long term opioid use for pain and sedation creates tolerance, leading to an increased dose of opioid medications. Further, opioid withdrawal and physical dependence can occur from the doses, which can lead to a final result of opioid-induced hyperalgesia.

For unrelieved pain, there are physiological and psychological results that can lead to future issues in the pediatric population. Stress activation of hypothalamic-pituitary-adrenal axis or the renin-angiotensin-aldosterone axis can result in fluid retention, hypertension, impaired tissue oxygenation, or compromised immunity. On the psychological end, unrelieved pain can result in anxiety, depression, impaired sleep, or PTSD.

Gigli mentioned that any adolescent with neonatal abstinence syndrome (NAS) should be monitored for 5 days, using tools such as supporting nonpharmacologic interventions and coordinating necessary help for the mother.

For the treatment of NAS, although many studies have found recommendations and possible solutions, there is still so much to be learned, according to Gigli.

“Morphine should not be our first choice for treatment, but currently it is used the most often,” Gigli said. “Methadone or buprenorphine should be considered first.”

On a scale of adolescent opioid misuse, Gigli addressed that 1 in 5 adolescents will misuse opioids, using without a prescription or not as prescribed. Misuse can be associated with housing instability, history of victimization, friends who misuse opioids, and trouble with family.

Screening, brief intervention, and referral to treatment, or SBIRT, medications, behavioral therapy, and family-centered approaches are the top recommendations for adolescent treatment. More resources can be found at FindTreatment.gov.

REFERENCE

Gigli KH. Medication-based treatment: a guide to managing opioid use disorder for the pediatric-focused APRN. 2020 NAPNAP Virtual Conference.