OPIOID USE IN ADOLESCENTS 1

An Overview of Opioid Use In Adolescents

Nursing Research

Youngstown State University

Ms Heasly

James Humphrey, Briana Lytle, Mary Jo Miller, Marissa Marzano, Audra Picuri

March 31, 2021

OPIOID USE IN ADOLESCENTS

Abstract

Through a cooperative research project it is the goal of this research paper to develop an

understanding of the role of adolescent opioid drug education in the prevention of adolescent

opioid addiction. Research shows that, as early as the 9th grade, students not only know about

drugs, but have experimented with various drugs as evidenced in the research of Emily Patry,

Jeffrey P. Bratberg, Ashley Buchanan, Andrea L Paiva, Sara Balestrieri, and Kelly L. Matson in

Rhode Island. The study surveyed 969 students and found that “19% reported use of marijuana,

3% heroin use, and 21% nonmedical use of prescription opioids” (Patry et al., 2019). In

Wisconsin 190 students from three different high schools were surveyed and the researchers

found that “most of their education regarding opioids came from internet search engines

(67.6%), talking with parents (56.7%), healthcare professionals (54.9%), and online videos

(42.3%)” (Olufunmilola, 2020). The evidence shows that adolescents by high school already

have at the very least a basic knowledge of opioid or other drug use and at the most have already

experimented with, contemplated the use of, or know someone who has used opioids or other

drugs (Olufunmilola, 2020). Another thing the study shows is that there is significant opportunity

for both the health care systems and educational institutions to develop early adolescents opioid

education programs to increase understanding and prevent possible future addiction. The

research also demonstrates that physicians also must be educated about the higher risks of

adolescents in developing opioid addictions when they are prescribed such medications.
OPIOID USE IN ADOLESCENTS

An Overview of Opioid Use in Adolescents

Intro

Is there a correlation between early adolescent opioid education and future addiction?

The purpose of this research paper will develop a better understanding of the opioid addiction in

adolescent populations and the role of education in preventing opioid addiction in the first place.

There has already been a significant amount of research on the causes of adolescent opioid

addiction from things such as experimentation, peer pressure, and over-medication. Researchers

are also now looking at the value and role of education in the healthcare system, family unit, and

adolescent realms. The goal of this research project will be to understand the correlation between

identifying a possible opioid addiction and prevention of the addiction in the first place through

education.

It is not uncommon for adolescents in all age groups to be prescribed opioids for pain

management either postoperatively or post injury. It becomes more common as the children’s

age rises into the teenage years. There is significant evidence that this is because this age group

has transitioned from pediatric primary care to adult primary care. Another complicating factor is

that these adolescents are treated more as adults in the hospital setting whether it be in the

Emergency Department or the Operating Room. So where should opioid education be focused?

On the health care provider? The family of the child? Or the child themselves?

A recent research study conducted in eight different 9th grade public High Schools in

Rhode Island revealed that “19% of the 9th grade students reported use of marijuana, 3% heroin

use, and 21% nonmedical use of prescription opioids” (Patry, 2019). The research went on to

show that after organized educational programs were delivered to the students “the students

showed a greater understanding of opioid misuse, overdose response, and recovery resources”
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(Patry, 2019). This research, though extremely important, leads to the much greater question of

when should organized opioid and drug use education begin? A second research project

completed in Wisconsin by surveying 190 high school students from three different high schools

revealed that “83.5% considered using someone else’s opioid medication as misuse. 85.2%

admitted to using opioids at a higher dose or frequency. 67.6% considered using a prescription

opioid after the expiration date had passed” (Olufunmilola, 2020). These students reported that

their information and/or education regarding opioids “came from internet search engines

(67.6%), talking with parents (56.7%), healthcare professionals (54.9%), and online videos

(42.3%)” (Olufunmilola, 2020). The significance of both of these research projects is that the age

groups in question already have a great deal of knowledge and understanding when it comes to

opioid use, addiction, and overdose. The key, then, is to develop a better understanding of when

organized opioid education should be started both in the health care setting as well as the school

systems.

Post-Surgical Prescription Opioid Use

After surgery, some type of opioid is typically prescribed to adolescents to alleviate their

level of postsurgical pain. Patients in this age group, most likely, have never been exposed to

these types of drugs until getting surgery, therefore, increasing their risk of developing opioid

abuse by introducing it. If possible, postoperative opioid pain control is best to be avoided at all

costs through using alternative measures. Other alternative medications besides opioids consist

of acetaminophen or Tylenol, nonsteroidal anti-inflammatory drugs aka NSAIDS (Ibuprofen,

Motrin, Aleve) and Antidepressants (Brennan, 2019). According to Dr. Lorraine Kelley-Quon,

there are three main principles in regards to opioid use for pain management, “First, opioid

misuse is a significant risk, especially for adolescents. Second, many effective non-opioid
OPIOID USE IN ADOLESCENTS

alternatives have been proven to be effective in managing pain for children after surgery. Lastly,

patients and families need to be educated about what an opioid is, how it should be used, the risk

associated with prescription opioid use, and how to safely dispose of leftover opioids” (Lewis,

2020).

According to a study presented by University of Michigan researchers at the American

Academy of Pediatrics National Conference and Exhibition on Sept. 2017, it found that one in 20

young adults continues to receive opioid prescription refills for a long period post-surgery

(Mostafavi, 2017). This study indicates, “Nearly 5 percent of patients 13- 21 who had common

surgical procedures continue to receive opioid prescription refills 3- 6 months after surgery”

(Mostafavi, 2017). Mostafavi’s study (2017) consisted of 88,637 privately insured adolescents

who averaged out to age 17 and never used any type of opioid prior to the procedure. The data

was analyzed between Jan. 1, 2010 and Jun 30, 2015. They looked at 12 common procedures

which consisted of tonsil or adenoid removal, hernia repair, cholecystectomy and scoliosis

(Mostafavi, 2017). Of the 88,637 patients, 4,343 of them got refills 90 to 180 days after surgery

(Mostafavi, 2017). Depending on the surgery, most do not require the need of opioids after 3-6

months. Especially in adolescents, as they typically heal a lot faster so their post-surgical

recovery should not be as extensive. At this point, if they are having some pain or discomfort, a

Tylenol or ibuprofen should be used.

When patients get refills, the doctor does not necessarily know what is done with them.

They could be used by the patient, stored or given elsewhere. Calista Harbaugh, M.D. who was

also a part of the research group indicated, “Doctors need to be aware that refilling opioid

prescriptions for teens can be a problem by either increasing the risk of dependence or increasing

access to medications that may be distributed to other youth” (Mostafavi, 2017). Adolescents are
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misled on the topic and believe that since it is a prescription medication, it is a safer drug to take

when compared to drugs like heroin (Mostafavi, 2017). This is not the case. These prescription

opioids are just as dangerous and have the same addictive properties (Mostafavi, 2017). This

shows that a lot of patients and their family members are uneducated on the possible outcomes

from prescription opioid abuse.

Education is key. Teaching these young adults and their parents about the possible

negative outcomes of continuous opioid use as well as how to dispose of the medication

appropriately can help reduce the risk of addiction. Harbaugh says, “Surgeon’s and providers

should also discuss these issues with patients and their families to prevent problems and provide

help for patients still seeking refills three or more months after the procedure” (Mostafavi, 2017).

Pain is a high priority after a patient goes through a surgery. However, if a doctor notices an

opioid medication refill months after surgery, this is when the doctor should step in to talk about

the potential problems of prescription refills.

Adolescents and Family

How adolescents are raised and the environment they grow up in is crucial to their

development and success. Parents and family members contribute to a large part of adolescent

use. Children and adolescents with parents that are abusing opioids are often subject to neglect as

their parents are focused on seeking out drugs rather than focusing on the schooling, health, and

safety of their children. One study found that in the 40 states tested children victims of substance

abuse less than a year old was 9.8%.(Morton & Wells,2017) 18.2% were less than one month

old, 3.2% were one month old, and those two months to eleven months were 3.2%.(Morton &

Wells, 2017).
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The children of substance abusers can experience loneliness, fear of being unwanted, and

may experience emotional effects if they see a family member use opioids to the point of death.

Opioids often cause people to be irrational and angered. According to a 2009-2014 study 3% of

children under 17 reports living with a parent with substance abuse disorder that causes strain on

their relationship (Romanowicz et al., 2019). Children will then blame themselves for anything

that goes wrong with their family because they don’t quite understand. Family members that can

be interrupted before reaching the point of death are put into treatment. Approximately 1/3 of

mothers who seek treatment for opioid abuse have children that are removed from the home

because they are unable to care for the child (Winstanley & Stover, 2019) The children, mostly

aged five younger are most often placed in foster care, which increases the child’s chance of

having behavioral problems and mental health issues (Winstanley & Stover, 2019). Foster care

systems have many children coming in and can not keep up with the demand due to limited

seeking families and services. This can cause the children to be at increased risk of engaging in

violence and other drug use. Having the children in foster care does however have more effect on

the parent(s) to take treatment more seriously as they do not want to lose custody of their child.

April Dirks says that nearly 1.2 million social work cases have parental drug abuse as their main

cause and continues to rise by 36% (Morton & Wells, 2017).

Having the children grow up in environments where they are seeing a family member

abuse opioids or inflicting the use on children can cause the children to abuse them as

adolescents or later in life. Winstanley says that approximately 769,000 adolescents misused an

opioid prescription and 103,000 overdosed on an opioid in 2017 (Winstanley & Stover, 2019)

More than 170,000 children are accidentally taking the opioids it could be because the parent

gives it to them or because leaves the substances lying around ( Brundage, Fifield, & Partridge,
OPIOID USE IN ADOLESCENTS

2019). One study found that the reason behind children under 5 obtaining these opioids was poor

storage. 34.8% were because the product was in reach of the children, 13.6% because of

inappropriate storage, and 13.3% were obtained from mom’s purse (Allen et al., 2017).

The same 15 yearlong studies looked at exposure to opioids in those under 20 years old.

The study not only looked at how many children were exposed to opioids but also what type of

opioids. The most common opioid exposure was found in children under 5 (59.7) by teenagers

(29.9%) (Allen et al., 2017). The study found that 56.1% of the opioid substance abuse was

unintentional as the most common reason along with 24.7% being given the wrong medication

and incorrect dose (13.7%) (Allen et al., 2017).

Exposure to opioids as a child causes them to be used later in life. One study found that

between 1999 and 2016 overdose death for ages 15-19 increased by 268.2% (N=7,(921) due to

the early exposure in childhood (Moore,et al., 2019)The study focused on 30 youth aged men of

different opioid background such as in treatment, being prescribed them, and opioid naïve. They

focused on the prevention of opioid use. The participants found the use of skits and videos to be

very beneficial in educating adolescents on the risks of opioids addiction and how to properly

use them.

Patterns

Opioid misuse in the US has become not only a crisis, but an epidemic within the past

twenty years. Prescription Opioid use is now a leading cause of death and injury amongst

adolescents (Hudgins, et al., 2019). In a study done by, Joel D. Hudgins, et al., they found that

opioid exposures accounted for over twelve percent of all deaths in 2016 among fifteen to twenty

four year olds, which represents a four fold increase since 2001. In this study the prevalence of

opioid use and misuse with or without use disorder, sources of prescription opioids, and
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prevalence of additional substance use was recorded across the span of a year. Opioid use

disorder is described as "recurrent use which causes clinically significant impairment, including

health problems, disability, and failure to meet major responsibilities at work, school, or home”

(Hudgins, et al., 2019, para. 15). In order to conduct this, survey responses were taken randomly

from the National Survey on Drug Use and Health in the years 2015 and 2016 and the age groups

ranged from, adolescents: twelve to seventeen, and young adults: eighteen to twenty five

(Hudgins, et al., 2019).

The sample of adolescents and young adults that was obtained in this study, evidenced

that 27.5% reported using a prescription opioid within the past year (Hudgins et. al., 2019). It

was concluded that when adolescents are exposed to prescription opioids, they have a higher risk

of opioid misuse after highschool. Researchers found that, “High school seniors receiving a first-

time medical prescription for an opioid have been shown to have a 33% increased risk of future

opioid misuse after high school” (Hudgins, et al., 2019, para. 29). Furthermore, prescription

opioid use among this age group is also linked to advance into another deadly drug, heroin. This

was concluded in a study done by the National Survey on Drug Use and Health,

“from 2004 to 2011 showed that the hazard of heroin initiation was 13 times higher

among adolescents and young adults 12 to 21 years of age with a history of nonmedical

prescription opioid use compared with those without such prior use. Overall, 76% of

respondents who reported a history of heroin use had previously engaged in nonmedical

use of prescription opioids” (Hudgins, et al., 2019, para. 29).

This infers that adolescents and young adults that engage in prescription opioid misuse

are more likely to have future opioid use as they grow into adults. Prescription opioid used in this
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age group also leads to further substance abuse (Hudgins, et al., 2019) These substances can

include cocaine, hallucinogens, inhalants, tobacco, and alcohol.

When addressing how these adolescents and young adults obtain prescription opioids, it

was found that they were mostly obtained for free by friends, relatives, or a single prescriber and

less often obtained by a drug dealer or multiple prescribers (Hudgins, et al., 2019). Hudgins et al.

(2019) states that findings indicate nearly half of adolescents and 58% of young adults misusing

opioids receive them from friends and relatives. And 25.4% of adolescents and young adults

obtained opioids from the healthcare system (Hudgins, et al., 2019). This creates a turnaround for

how this epidemic continues to be a problem within the United States. Adolescents are receiving

these opioids for free and then selling, trading, or giving them away to others stimulating a

snowball effect (Hudgins, et al., 2019).

To further take a look at prevention and treatment of prescription opioid use, the fact that

at this age level opioids are mostly obtained from family members, friends, and healthcare

providers should be taken into account. Hudgins et al., (2019) suggests that healthcare providers

should consider screening adolescents with opioid misuse and other substance use. They should

also have established intervention plans available such that give the opportunity for substance

use treatment and referral options (Hudgins, et al., 2019).

Treatments

When beginning to consider treatments or interventions for an adolescent with opioid use

disorder, it is important to evaluate the patient’s motivation and willingness to comply with

treatment (Verma, 2020). Treatment planning should also be done with both the patient and

family to ensure their individual needs are met (Verma, 2020). It is important to set a realistic
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11

plan and goals that will aid the patient in rehabilitation such as establishing academic or career

goals and improving personal relationships (Verma, 2020).

Psychotherapy is often used to treat Opioid Use Disorder (Verma, 2020). Multiple family

therapy models have been used to treat patients with substance use disorder including functional

and structural family treatments (Verma, 2020). Structural family therapy addresses issues with

functioning within a family. Functional family therapy is used as an intervention and prevention

program for families with at risk youth. It is necessary for the clinicians to develop good rapport

with their patients (Verma, 2020). According to Verma (2020), clinicians are unable to share any

information about the patient’s substance use or behaviors related to substance use unless

someone is at risk or consent is received from the patient. Another option for patients to utilize

alongside treatment is support groups for substance use disorder or sober housing options

(Verma, 2020).

Pharmacotherapy is another option for treatment, but much fewer adolescent aged

patients are given medication to treat Opioid Use Disorder than adult patients (Zimlich, 2017).

There are significant disparities amongst a variety of demographics such as age, gender, and race

when it comes to prescribing pharmacological interventions (Zimlich, 2017). According to

Zimlich (2017), age played a significant factor that affected the number of patients receiving

medication. Only approximately 2.4% of adolescents receive medication assisted treatment for

heroin use and 0.4% for prescription opioid use, compared to 26.3% and 12% of adults (Verma,

2020). The most common medications used include opiates such as methadone and

buprenorphine for detoxification (Verma, 2020). Maintenance treatment may be considered as

well if the patient's history of opiate use is long term and psychotherapy and pharmacological

detoxification treatments have already been attempted unsuccessfully (Verma, 2020).

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What works for some patients will not work for all, this is why it is important to make

individualized treatment plans with pharmacological interventions, psychotherapy or both

(Verma, 2020). Allowing the patient and family to provide input during the creation of the

treatment plan will allow for the most success in abstinence (Verma, 2020).

Conclusion

Proper education on opioids and substance abuse will help lead to a decrease in addiction

rates of young adults. Opioid abuse is a major problem affecting both children and adults in our

area, and is considered a leading cause of death among adolescents. Education on the negative

outcomes of addiction is important for children to start learning at a young age. Providing

education is beneficial for family as well because a child’s environment can affect behaviors and

patterns picked up by the child later in life. Prevention is the best option when it comes to

handling this epidemic, but there are treatment options available to those struggling with

substance use disorder.

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