Putting a Stop to Opioid Related Hospitalization in Children

By Grace Lee, Sakina Hussain and Alice Kim, clinical pharmacists at CHOC

Opioids are a type of medication used to treat pain by blocking pain signals to the brain and decreasing the body’s perception of pain. When used appropriately under the supervision of a physician, prescription opioids are safe and effective medications. However, they are not without potentially serious side effects.

“The past two decades have seen a medical industry-wide emphasis on recognition and treatment of pain. This may have resulted in greater customer satisfaction, but it has led to more opioid products available in more homes than ever before,” says Dr. James Cappon, CHOC’s Chief Quality and Patient Safety Officer. “There are local and national increases in both accidental ingestions and poisonings in children and adolescents, and intentional overdoses in adolescents, too often with serious or even fatal results.”

Examining the Increase in Opioid-Related Hospitalization in Kids and Teens

A recent research study from the Yale School Medicine confirms this observation. Over a 16-year period from 1997 to 2012, a total of 13,052 hospitalizations for prescription opioid poisonings in children were identified. The number of young children aged 1-4 years admitted for opioid-related hospitalization (ORH) doubled, while a similar increase was seen among teens aged 15-19 years.

The reasons for these hospitalizations also varied by age group: children ages 1 to 4 were hospitalized primarily for accidental ingestion, while a majority of teenagers took the drugs with the intent to commit suicide or unintentionally overdosed when taking the drugs for recreational purposes, according to the study.

Side effects of opioid use and abuse

Commonly prescribed opioids for moderate pain include hydrocodone, oxycodone or morphine. Potent opioids such as fentanyl are used to treat severe pain related to cancers and other chronic illnesses.

Opioids can cause severe constipation, nausea, stomach upset, rash, drowsiness and confusion. If taken in excess, there is potential for dependence. Opioid overdose can result in dangerously slow breathing, low blood pressure and coma. In particular, opioids and alcohol are a notoriously deadly mixture.

Safeguarding our children

This study underscores the dangers of prescription opioids, which can often be more accessible than street drugs. “While greater awareness around reducing opioid dependence and prescribing is developing in the medical community, it is extremely important that our patients and families partner in keeping our children safe,” says Dr. Cappon.

Safeguarding our children starts with education and developing a healthy respect for these powerful pain killers. Precautions should be taken to store these medications away from children. Parents can also learn to identify signs and symptoms of opioid overdose to in order to seek help as soon as possible. Some practical tips include:

  • Safe storage – keep all medications away from your child’s reach and sight. Store in locked cabinets, if possible.
  • Safety cap – when filling prescription medications at pharmacies, request child resistant caps to be placed on the medication bottles to prevent easy access.
  • Safe administration – when giving medication to you child, double check the directions on the medication label. Liquid medications should be measured accurately when giving to your child. Keep track of how much medication is left over.
  • Safe disposal ­– expired medications or those that are no longer needed should be disposed of properly. The Food and Drug Administration recommends disposing some medicines, including opioids, by flushing them down the toilet or sink. If you are not sure whether your unused medication can be safely flushed, please check online for community drug take back days in your area.
  • Be aware of medication side effects – be familiar with common side effects of opioids such as nausea, vomiting, constipation, urinary retention, dizziness, drowsiness and confusion.
  • Recognize signs and symptoms of overdose – overdose is life-threatening. If you notice any of the following symptoms, call 911 immediately:
    • Pale face
    • Clammy skin
    • Limp body
    • Blue/purple lips and fingernails
    • Choking or gurgling noises while asleep
    • Cannot be awakened or are unable to speak
    • Slow/no breathing or heartbeat
  • Recognize signs and symptoms of inadequate pain control – it is important to control your child’s pain adequately with the right medications. Besides discomfort, inadequate pain control can lead to drug-seeking behaviors. Talk to your provider about the addition of non-opioid medications that can help with pain.
  • Be aware of your child’s physical and mental health ­– studies have shown that there is an increased risk of substance abuse (including opioids) in children with psychiatric disorders. Be involved with your child’s health and have an open discussion to prevent abuse.

For reference, a list of opioids and their brand names:

Opioid Brand Name
Fentanyl Actiq, Duragesic, Subsys, Lazanda, Fentora, Abstral
Hydrocodone Lortab, Vicodin, Norco  Hysingla ER, Zohydro ER
Hydromorphone  Dilaudid
Methadone Dolophine
Meperidine Demerol
Morphine MS contin, Kadian, Avinza, Embeda (with naltrexone)
Oxycodone Percocet, Oxycontin, Roxicodone, Oxecta, Xtampza ER, Oxaydo

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Getting your Little Patient to Follow Medication Directions

By Grace Lee, clinical pharmacist at CHOC

Grace Lee
Grace Lee, clinical pharmacist at CHOC, offers tips on getting children to follow medication directions.

Medication compliance is defined as how well a patient follows the directions written on a prescription. In a perfect world, we would follow the instructions ordered by our doctors all the time. However, there are many reasons why this doesn’t always happen. Poor compliance can lead to the failure of a treatment plan in many diseases. Also, if the doctor assumes that a patient is taking his or her medications as directed when they actually aren’t, this may lead to unnecessary dose adjustments since the doctor thinks the medication is not working.

Maintaining perfect compliance is difficult but not impossible. While all of us are prone to forget a dose of medication here and there, there are ways to improve our chances of remembering. Consider these tips on improving medication compliance:

  • Try linking medication doses to other daily activities, such as eating meals, brushing your teeth, or going to bed.
  • Create a medication schedule on paper or use a pillbox that contains days or a week’s worth of medication. This is an especially good idea when multiple care takers are involved, or if the child spends time in more than household. Refill the box at the same time every week.
  • Alarms on your watch or smartphone are another way to remind yourself when it’s time to take or give medicine. Many smartphone apps allow you to set reminders to take or give a dose, obtain refills, and even provide drug information.
  • Sign up for automated refill reminders at your pharmacy or consider a mail-order service that can deliver up to 3 months of medication at a time so you don’t run out.
  • If the cost of your medicine makes it difficult to afford refills, speak with your doctor or pharmacist about generic or alternative options.
  • Since compliance dramatically decreases with the complexity of the medication regimen, ask your doctor or pharmacist if the regimen can be simplified by using combination products, longer acting formulations, or if certain drug can be eliminated.

Non-compliance could also result from not understanding the importance of taking the medicine or disliking the side effects.  Having a trusting, open relationship with your health care provider is the best way to overcome these concerns. Be honest with your doctor – if it is unclear why you need a certain medication, clarify it with your prescriber. Often there are other medications that can be tried if a side effect is unbearable. Do not take alternative or herbal medicines, assuming they are safer than your prescription medications, without consulting with your doctor or pharmacist first.

The teenage years are an especially challenging time to maintain medication compliance. Often time parents want to hand over the responsibility of administering medicines to their teen, but they may be forgetful or feel embarrassed to take their medications in front of their peers. Smartphone apps are especially good for this age group. Setting up a support system involving the school nurse or close friends can be useful when you are not around to monitor. If embarrassment is a concern, encourage them to take the medications privately. For parents who want to monitor how well their child is doing keeping up with medications, there are bottle caps that count the number of times a bottle is opened, or devices that record how many times an inhaler has been used. Remind them of the positive rewards to staying healthy, such as the ability to participate in sports, go out with friends, and even drive.

For a higher fee, there are pill bottles that can be programmed to flash or make noises when a dose is overdue, or personalized rolls of presorted medications that come in a dispenser.  Like any habit-forming behavior, the tips on improving medication compliance that will work for an individual or family will vary. The important thing is to develop a plan and stick with it. With the help of your doctor and pharmacist, strong compliance is achievable!

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CHOC Pharmacy’s Med-to-Bed – One Less Thing Before You Go

Bringing a child home from CHOC just became easier. Beginning this month, our patients, and their parents, will be discharged with home medications already in hand. That’s right — no more stopping by a pharmacy thanks to a new program that improves patient safety and helps prevent hospital readmissions.

Following a successful pilot program in the CHOC Medical/Surgical units recently, the CHOC Med-to-Bed care program returns and expands services to all patients, Monday through Friday.

The family-centered care program brings an outpatient pharmacist to each patient’s bedside before discharge. There, the pharmacist provides the discharge medications to take home, discusses instructions and side effects, and provides hands-on teaching as needed.

This convenient, one-on-one service offers several advantages:
• Improves patient safety by ensuring patients go home with the medications they need.
• Reduces the possibility of errors and medication-related hospital readmissions by ensuring parents know how to correctly use the medication and manage any side effects.
• Builds patient and parent confidence through hands-on teaching for related medical equipment, including syringes and inhalers.
• Resolves any potential barriers in filling prescriptions caused by transportation, insurance authorization or payment issues.

According to medical literature, medication management errors are some leading factors in hospital readmissions. While the “med-to-bed” concept is becoming popular in hospitals across the country, CHOC is one of the first hospitals in the region to implement this program.

CHOC Pharmacy Director Grace Magedman said the pilot program was tested on the hospital’s medical/surgical units because of their high patient volume.

“Our team found the one-on-one time with patients and their parents right before discharge to be very rewarding,” she said. “We could answer questions, discuss possible side effects, and provide hands-on teaching. This helps ensure that patients are taking their medication correctly at home — and avoids a trip back to CHOC.”

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Household Poisoning Hazards

Aufpassen: Baby will mit Putzmittel spielenPoison control centers across the country receive more than two million calls a year. Most of the calls involve children ages 5 and under who have been accidentally exposed to poisons in the home.

Considering the active and curious nature of young children, parents need to take extra precautions to prevent their little explorers from getting into dangerous household items.

Dr. Lilit Minasyan, who works in the Emergency Department at CHOC, offers the following tips to help prevent accidental household poisonings:

  • Store all vitamins, narcotics, over-the-counter medications, household cleaners, cosmetics and liquor in a locked or latched cabinet out of the reach of children.. Even items that may seem harmless, like iron-rich vitamins meant for adults, could be dangerous if kids ingest them in large quantities.
  • Never tell children that vitamins or medications are candy.
  • Always keep pills, household cleaners, liquids and other possibly toxic substances in their original containers. Don’t put them in soda bottles or food containers; your child might eat or drink from them.
  • Don’t keep cleaning supplies, including dishwasher detergent and dishwashing liquids, under the kitchen sink where kids can easily get to them.
  • Keep hazardous automotive products, locked and out of a child’s reach, in the garage.
  • While cleaning the house or using household chemicals, never leave the bottles unattended if a small child is present.
  • Memorize the national poison control center phone number – 1-800-222-1222 – and program it into your cellphone.

If you think your child has ingested a toxic substance, don’t induce vomiting, says Dr. Minasyan. A child could choke on the vomit or the vomit could travel into the lungs. Some cleaners and substances will cause internal burns in the mouth and throat, so it’s important to avoid further injury.

If your child is unconscious, not breathing, or having convulsions or seizures, call 911. If your child has mild or no symptoms, call the Poison Control Center at 1-800-222-1222.

To learn more about poison prevention in the home, please visit choc.org/health.

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    Medication Safety in the Home

    Every 10 minutes in the United States, there’s a child under the age of 6 taken to an emergency department for medication poisoning. Most of the incidents occur in the home, a CHOC pharmacist tells CHOC Radio.

    In podcast No. 23, Dr. Shannon Bertagnoli offers tips to help prevent children from getting into medications:

    • where to store medicine;
    • what to do with visitors; and
    • how to take medication

    She also offers online resources for caregivers interested in learning more.


    CHOC Radio theme music by Pat Jacobs.