AMERICAN ACADEMY OF DEVELOPMENTAL MEDICINE & DENTISTRY
Do I Have To Worry About an Opioid Addiction Too?
BY H. BARRY WALDMAN, DDS, MPH, PHD AND STEVEN P. PERLMAN, DDS, MSCD, DHL (HON)
"(In the United States), more people than ever are dying from opioid overdose; in 2016, over 42,000 people were killed by opioids. Across 52 areas in 45 states opioid overdoses increased by 30 percent from July 2016 through September 2017… Some opioids such as heroin, are illegal. However, many opioids are legal and are prescribed by health care providers to treat pain; these include oxycodone, hydrocodone, codeine and morphine… Use of these prescription drugs for short durations, as prescribed by a doctor I, is generally safe…" 1
"In 2016, 3.6 percent of adolescents age 12 to 17 reported misusing opioids over the past year… the CDC estimates that for every young adult overdose death, there are 119 emergency room visits and 22 treatment admissions… Signs of opioid misuse include: drowsiness, constipation, nausea, dizziness, vomiting, dry mouth, headaches, sweating and mood changes…" 1
"The estimated cost of the epidemic nationwide in 2016 alone was $95.8 billion, and its estimated cost between 2001 and 2017 exceeded $1 trillion from lost productivity and increased spending on health care, social services, education, and criminal justice." 2
The American Academy of Developmental Medicine and Dentistry (AADMD) was organized in 2002 to provide a forum for healthcare professionals who provide clinical care to people with neurodevelopmental disorders and intellectual disabilities (ND/ID). The mission of the organization is to improve the quality and assure the parity of healthcare for individuals with neurodevelopmental disorders and intellectual disabilities throughout the lifespan.
Living with a disability can have a serious impact on a person's well-being, especially when that disability is associated with chronic pain. The challenges of living with daily pain contributes to substance abuse rates that are two to four times higher among individuals with disabilities than in the general population.3 Every 25 minutes, an infant is born suffering from opioid withdrawal (a pre-birth consequence from mom), and an estimated 21,732 infants were born in 2012 with neonatal abstinence syndrome, a drug withdrawal syndrome. 4
The risk factors for adolescent substance abuse are similar to the behavioral effects of learning disabilities: reduced self-esteem, academic difficulty, loneliness, depression and the desire for social acceptance. Thus, researchers theorize, learning disabilities may indirectly lead to substance abuse by generating the types of behavior that typically lead to substance abuse. 5
Nevertheless, in the last decade there has been significant controversy about the appropriateness, efficacy, safety, and wisdom of treating chronic pain patients with opioids. Arguments against their use have included concerns about tolerance, dependence, addiction, persistent side effects, and interference with physical or psychosocial functioning. However, considerable experience and research suggests that in appropriately selected patients, opioids have a low morbidity, and a low addiction potential, and in addition to the primary analgesic action, can facilitate reduction in suffering, enhance functional activity level, and improve quality of life without significant risk of addictive behaviors.6
Although evidence is limited, the expert panel of the American Pain Society and the American Academy of Pain Medicine concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids.7 Some patients are at risk.6,7
SOME LESSONS IN ANATOMY AND PHYSIOLOGY
The brain is wired to encourage life-sustaining and healthy activities through the release of dopamine. Everyday rewards during adolescence—such as hanging out with friends, listening to music, playing sports, and all the other highly motivating experiences for teenagers—cause the release of this chemical in moderate amounts. This reinforces behaviors that contribute to learning, health, well-being, and the strengthening of social bonds.8
The "high" produced by drugs represents a flooding of the brain's reward circuits with much more dopamine than natural rewards generate. This creates an especially strong drive to repeat the experience. The immature brain, already struggling with balancing impulse and self-control, is more likely to take drugs again without adequately considering the consequences.9 If the experience is repeated, the brain reinforces the neural links between pleasure and drug-taking, making the association stronger and stronger. Soon, taking the drug may assume an importance in the adolescent's life out of proportion to other rewards.
"The development of addiction is like a vicious cycle: chronic drug use not only realigns a person's priorities but also may alter key brain areas necessary for judgment and self-control, further reducing the individual's ability to control or stop their drug use. This is why, despite popular belief, willpower alone is often insufficient to overcome an addiction. Drug use has compromised the very parts of the brain that make it possible to 'say no.'"8
POTENTIAL SYMPTOMS IN SCHOOL-AGED CHILDREN
CHILDREN • "Impaired verbal performance, reading, and arithmetic skills • Poor mental and motor development • Memory and perception problems • Attention deficit hyperactivity disorder (ADHD) • Developmental delays • Speech problems, including challenges in producing speech sounds correctly or fluently or difficulty with voice or resonance • Language disorders, including trouble understanding others (receptive language) or sharing thoughts, ideas, and feelings (expressive language) • Impaired self-regulation • School absence, school failure, and other behavioral problems • Depressed respiration or hypoxia • Reduced decision-making abilities and behavior regulation • Poor response to stressful situations • Poorly developed sense of confidence or efficacy in task performance • Depressive disorder • Substance use disorder" 10
GROWING PAIN: Today, increasing attention is focused on the rights of all children to receive adequate pain control. Yet, despite our continuing efforts to make children's pain control a higher priority throughout the world, serious challenges remain.
REALITIES
Individuals with disabilities are a growing population that is confronted by multiple disadvantages from social and environmental determinants of health. "In particular, the 7 to 8 million people with an intellectual disability (ID) suffer disproportionately from substance (i.e. illicit drug) use problems, largely because of a lack of empirical evidence to inform (them, regarding) the availability of prevention and treatment efforts."10 (Emphasis added) While the prevalence of alcohol and illicit drug use in this population is low, the risk of having a substance-related problem among ID users is comparatively high. Compared with substance abusers without ID, ID substance abusers are less likely to receive substance abuse treatment or remain in treatment. 11
A report from Canada provides further commentary on substance-related and addictive disorders (SRAD) among adults with and without intellectual and developmental disabilities. The prevalence of SRAD among adults with ID was considerably higher than for adults without ID in Ontario. 12
"As a result of improved efficacy of treatments and care for life-threatening pediatric conditions, the survival of children with serious congenital or acquired diseases in developed countries has increased during the last decades. Yet, many of these children have not been cured (e.g. those with cystic fibrosis) or they have disabling sequelae of their disease (e.g. cerebral palsy and juvenile rheumatoid arthritis) or its treatment (e.g. retinopathy of prematurity). The incidences of some other conditions, such as asthma and obesity, are rising. Therefore, the prevalence of chronic diseases in children and in young adults, which is a function of incidence and duration, has increased since the 1980s and will likely increase further." 13
"(In the past,) clinical decisions about whether children were experiencing pain and, if so, about the particular pain therapies required, were long based primarily on physicians' personal beliefs rather than on scientific evidence. Regrettably, common misbeliefs – that children did not feel pain as intensely as adults and consequently did not require similar analgesics and pervasive fears – that children were at heightened risk for opioid addiction and should receive minimal analgesic doses, caused many children to suffer needlessly. (Note: More than sixty years ago, one of us (HBW) was taught during his dental school training that the repeated movements and crying by pediatric patients during dental treatment were simply "childhood things" since the youngster really experienced little to no pain.) Unprecedented scientific and clinical attention subsequently focused on the unique pain problems of infants, children and adolescents – revealing the adverse impact of untreated postoperative pain and inadequately treated procedural pain for children with cancer.
The ensuing publicity as people learned that minimal anesthesia and analgesia represented 'the norm in pediatric postoperative management', rather than the exception, sparked a revolution. Clinical practice started to change so that children began to receive more appropriate analgesics at adequate doses and regular dosing intervals. Treatment emphasis also shifted gradually from an almost exclusive disease‐centered focus – detecting and treating the assumed source of tissue damage – to a more child‐ centered perspective – assessing the child to identify any environmental and psychological factors that contributed to pain, so as to target interventions accordingly.
Today, increasing attention is focused on the rights of all children to receive adequate pain control. Yet, despite our continuing efforts to make 'children's pain control' a higher priority throughout the world, serious challenges remain. In particular, the management of childhood chronic pain is a continuing problem in many centers, creating ethical dilemmas from patient‐centered, health care and societal perspectives." 14
SO, REGARDING YOUR CHILD WITH A DISABILITY, DO YOU HAVE TO WORRY ABOUT AN OPIOID ADDICTION TOO?
Unfortunately, like so many other parents raising their children at a time far different from that when they were raised, you have to be concerned with issues that seem far afield from the "usual" food, clothing, shelter and schooling issues. But growing up, your child could lend you a hand with your computer complexities which he/she learned to fix before they could write a clear sentence.•
ABOUT THE AUTHORS: H. Barry Waldman, DDS, MPH, PhD is a SUNy Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, Ny. E-mail: h.waldman@stonybrook.edu Steven P. Perlman, DDS, MScD, DHL (Hon) is the Global Clinical Director and founder, Special Olympics, Special Smiles and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine.
References 1. Department of Health and Human Services. Office of Adolescent Health Opioids and adolescents. Available from: hhs.gov/ash/oah/adolescent-development/substance- use/drugs/opioids/index.html Accessed November 21, 2018. 2. Normile B, Hanlon C, Eichner H. Antigoals Academy for State Policy. State strategies to meet the needs of young children and families affected by the opioid crisis. Available from: nashp.org/wp-content/uploads/2018/09/Children-and-Opioid- Epidemic-1.pdf Accessed November 21, 2018. 3. Wilson M. Able Well Organization. When addition, opioids, and disability meet. Available from: https:/ ncdj.org/2018/03/when- addiction-opioids- and-disability-meet Accessed November 22, 2018. 4. Ideas that Work. Intervention IDEAs for infants, toddlers, children, and youth impacted by OPIOID. Available from: osepi- deasthatwork.org/sites/default/files/IDEAslIssBrief-Opioids-508.pdf Accessed November 20, 2018. 5. Daw J. Substance abuse linked to learning disabilities and behavioral disorders. Available from: apa.org/monitor/jun01 disorders.aspx Accessed November 21, 2018. 6. Aronoff GM. Opioids in chronic pain management: Is there a significant risk of addiction? Current Review of Pain 2000; 4(2):112-121. 7. Opioid treatment guideline for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain 2009; 10(2):113-130.e22. 8. National Institute on Drug Abuse. Principles of adolescent substance use disorder treatment: A Research-Based Guide. Available from: drugabuse.gov/publications/principles-adolescent- substance-use-disorder-treatment-research-based-guide/introduction Accessed November 21, 2018. 9. Andersen SL, Teicher MH. Desperately driven and no brakes: Developmental stress exposure and subsequent risk for substance abuse. Neuroscience & Biobehavioral Reviews 2009;33(4):516–524. 10. Behnke M, Smith VC. Committee on Substance Abuse, & Committee on Fetus and Newborn. Prenatal substance abuse: Shortand-long-term effects on the exposed fetus (Technical Report), 2013. Available from: https:// mofas.org/wp-content/uploads/2015/01 Pernatal-Substance-Abuse-Short-and-Long-term-Effects-on-theExposedFetus2.pdf Accessed November 23, 2018. 11. Carroll Chapman SL, Wu LT. Substance abuse among individuals with intellectual disabilities. Research Development in Disability 2012;33(4):1147-56. 12. Lin E, Balogh R, McGarry, et al. Substance-related and addictive disorders among adults with intellectual and developmental disabilities (IDD): an Ontario population cohort study. British Medical Journal (open) 2016;6(9):e011638. 13. Van der Lee JH, Mokkink LB, Grootenhuis MA et al. Definitions and measurement of chronic health conditions in childhood: A systematic review. Journal American Medical Association 2007;297(24):2741-2751. 14. Ruskin DA. Caring for children with chronic pain: ethical considerations. Pediatric Anesthesia 2007; 17(6):505-508.