Year: 2024
Type: article
Abstract: The overdose crisis in the United States has been characterized by sequential “waves” involving (1) prescription opioids, (2) heroin, and (3) synthetic opioids such as fentanyl. Fentanyl continues to drive the current fourth wave of overdose deaths, with co-involvement of cocaine and methamphetamine. Pediatric deaths from fentanyl have increased more than 30-fold since 2013. Most of these deaths are among adolescents aged 15 to 19 and children 0 to 4 years. Over 40% occur at home, and over 87% are unintentional.1 Naloxone is an opioid antagonist that can reverse an opioid overdose within minutes and is, therefore, lifesaving when given in a timely manner. It is safe to give to infants, children, teens, and adults and has recently become available over the counter.2 Nonetheless, many who are at risk for fentanyl exposure and overdose are not provided naloxone.In this issue of Pediatrics, Terranella et al present the first national estimates on naloxone dispensing to youth.3 Between 2017 and 2022, dispensing of naloxone to pediatric patients increased 669%, suggesting that prescribers are responding to the overdose crisis. Despite this nearly 8-fold increase in prescribing, however, opioid overdose fatalities in youth continued to rise, nearly tripling during this time period. Pediatricians accounted for only 5.6% of naloxone prescribers. The authors conclude that pediatric health care providers have a key role in expanding access to naloxone to youth at risk for overdose.3Fentanyl prevalence continues to increase nationwide. In 2023, the United States Drug Enforcement Agency seized more than 80 million fentanyl-laced pills and nearly 12 000 pounds of fentanyl powder. Fentanyl-laced pressed pills are widely available and made to resemble prescription opioids and other prescription medications, such as benzodiazepines and stimulants. Fentanyl has also been found in methamphetamine, cocaine, and marijuana. It is, therefore, not only those with opioid use disorder who are at risk for overdose and death; unintentional ingestion is also common.4Although Terranella et al discuss various provider, pharmacist, and community efforts to increase naloxone distribution to youth,3 the routine prescribing of naloxone by pediatricians should also be considered. Most youth see a pediatrician for primary care, making the pediatrician’s office a key place to discuss harm reduction efforts for opioid overdose. Historically, the distribution of naloxone has focused on selective interventions: prescribing to those with opioid use disorder, history of overdose, or a substance use disorder. However, because of the current fentanyl epidemic, distribution of naloxone with universal intervention (without screening or selectivity) should be considered.Pediatricians have a well-established culture of discussing safety and prevention with families. Like promoting the safe storage of firearms or encouraging every home to have a fire extinguisher, pediatricians should consider prescribing naloxone at every health maintenance visit to ensure the safety of their patients and families. Routine discussion that naloxone should be readily available to all persons (regardless of personal or family substance use disorder history) removes stigma and provides an opportunity for open, nonjudgmental discussion around substance use with all patients and families. This may allow families to feel more comfortable discussing their own substance use challenges while providing them with life-saving medication that could prevent their child’s unintentional overdose as well as their own.In a recent issue of Pediatrics, Hadland et al discussed the importance of the pediatrician providing anticipatory guidance to prevent adolescent overdose, stressing that pediatricians should avoid fear-based approaches.5 We agree with Hadland’s recommendation to speak to adolescents’ strengths and empower them to keep themselves safe but also encourage interventions to keep all members of the family safe in the event of fentanyl exposure. To protect the child means also to ensure the safety of their parent or guardian. A recent study in JAMA Psychiatry estimated that 321 566 children in the United States lost a parent to drug overdose between 2011 and 2021.6 Pediatricians must respond to the overdose crisis by providing prevention resources to parents and families, decreasing the ripple effects of family instability, and breaking generational cycles of substance use and trauma.6Terranella et al discuss the cost of naloxone as a barrier to widespread access.3 We agree with the authors that enrolling more Medicaid-eligible patients and reducing copays at the time of sale could increase access. Although over the counter availability could improve access and lead to lower cost, it may have the unintended consequence of decreasing insurance coverage of naloxone.7 Pediatricians may connect with their community opioid education naloxone distribution programs for help with acquisition of free naloxone. In many states, providers, patients, and families may access naloxone at no- or reduced-cost through NEXT Naloxone (naloxoneforall.org) and its affiliated harm-reduction programs. Sharing this link with families is a simple, rapid, and no-cost intervention.We understand the dilemma pediatricians face at each visit, trying to fit 30 to 45 minutes of screening, examination, and anticipatory guidance into a 15-minute visit. Adding 1 more piece of education can seem daunting. However, using the phrase, “May I speak with you about ways to keep your family safe from overdose?” can be a great start to having open conversations to keep patients, families, and communities safer in the face of an ever-changing opioid epidemic.
Source: PEDIATRICS
Authors: Erin McKnight, Cynthia Holland-Hall
Institutions: Nationwide Children's Hospital, The Ohio State University
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4402493952