A Conversation with an Expert: The Opioid Epidemic and Pediatric Care

The opioid epidemic is a growing public health emergency in the United States. As the number of overdoses continues to rise, it is unavoidable that action must be taken to spread awareness, offer support, and pave a better path forward for those struggling with substance use disorders. The opioid crisis has continued to rise during the COVID-19 pandemic, due to increased feelings of isolation, anxiety, and depression. Unfortunately, adults are not the only members of the population impacted by this crisis. Individuals of all ages struggle with opioid addiction.

We spoke with Lynn Clark, Director of Advanced Practice for Anesthesiology for Children at Children’s Health in Dallas, TX, to find out first hand how the opioid epidemic is affecting children and teenagers, a population of opioid users who have less awareness, despite their serious challenges.

Why do you think there’s been such a dramatic increase in Opioid-related deaths, even before the start of the COVID-19 pandemic? 

Clark: “My background is in pediatric pain management. Previously, beginning in the late 90s and early 2000s, there was a push for complete pain management. We really pushed pain relief, and ‘no pain’ was the mantra. What we recognize is that as providers started to work toward that ‘no pain’, people were very focused on medicine and getting enough medicine to get the patient out of pain. When, in reality and what we know now, that is not the best answer. We need to have a much more multimodal perspective. In other words, we need to use non-medicine treatments in addition to a variety of medicines (not just opioids) to get to the best pain relief. I think that part of the increase in the use of opioids was that providers were telling patients the goal was no pain, so would prescribe them a large number of opioids.  Those excess opioids, if the patient didn't take them all, are sitting in dad or grandma's or medicine cabinet. More than 50% of teens who abuse prescription opioids get them from a friend or relative.  I think the availability and ease of getting to opioids, even for those who they're not prescribed for, is one thing that has contributed to the wide variety of legitimately prescribed drugs finding their way into the wrong hands.”

In your opinion, what aspects of Opioid addiction prevention and recovery are in the direst need for better funding, and why? (ie: If you were in charge of distributing resources, where would they go and why?) 

Clark: “I'm a pediatric provider so opioid addiction in the pediatric population is far less common than it is in the adult world, but we do know that it does occur, especially in teens and young adults. I think one reason that happens is people are doing chemical coping. They’re taking a medicine to make them feel better, either physically or mentally.  If whatever medicine they were taking isn't providing the same feeling any longer, they're going to either find something else either more addictive or more problematic for them or they're going to take more of it, which leads to overdoses. I think a larger focus needs to be put on the mental health part of this issue. From a teenage and young adult population, we need to really focus on mental health and how to help them gain better coping skills. I think we saw in the pandemic a swing from having an ‘average’ number of kids who have mental health issues to a much larger number of kids having mental health issues.  The pandemic created a different kind of stress with school closings, limited peer social interactions and less social support. I think they're trying to find ways to cope with loneliness, depression, and anxiety of being alone. And so they turn to something external-- what are they going to find? Whatever is easily accessible, like alcohol or what is in the medicine cabinet. We need to focus on the mental health aspects of care. We need better access to mental health care; we need more providers who take all types of insurance; we need to allow the providers the patient until they're better and not limit the number of visits. I think the whole evaluation and treatment of mental health issues is a huge issue and needs to be focused on.”

How does your organization identify your highest risk patients? 

Clark: “When we prescribe opioids to patients we complete an opioid risk assessment on them which includes assessing things like: do they have a history of opioid abuse in the past, is there a family history of opioid abuse, do they have a history of sexual abuse, and their age. Then if that assessment shows them at high risk, we refer them to a social worker to have further discussions about this because in the pediatric world we're not only assessing the kid but the whole family.”

If you could wave a magic wand, what would you do right now to solve the opioid epidemic? 

Clark: “There are two things I would do. One, I would focus on mental health to provide easy access and covered by insurance at no cost or low cost to the families  and I would put resources in the pediatrician's office, in the schools, in the downtown neighborhood mall. The second thing I would do is to educate providers who are prescribing opioids for acute pain and have them think about how many doses of drugs this patient really needs to go home with. Like a post-op kid with an appendectomy, don’t just send them home with 30 doses. The provider should estimate how long the pain will last.  Instead of 30 doses, I want the provider to think “this kid really only needs 12, because they're only going to take it for the first three days”. Conscious prescribing for acute pain will limit the number of opioids that are put in that kid’s medicine cabinet.”

Are there any apps or technological advancements that you see in other industries that you wish could be applied to opioid recovery? 

Clark:  “As a provider prescriber you recognize that there are lots of medication options out there, but what other non-medicine options are there? If Lynn ruled the world, we could create an app that said ‘this kid is 15 years old, they had an appendectomy, their normal pain would be X amount of days and they need this many drugs, but you should also give them ice’ and give them an explanation. I would really lay out a treatment plan so that the provider isn’t limited to only medications but has non-medicine options that will optimize pain relief. We don't want to swing the pendulum the other way and not give them pain relief. Filling in the treatment gaps would be great.”

Clark: “I think another thing that technology could provide is a mental health directory. the provider or the patient types in a zip code, and the app gives you providers available in your area, support groups treatment options,. We need to make it easier to find that information, and we need it to be easier for providers to refer out.”

What are the biggest barriers in getting treatment for opioid users? What do you think are the biggest barriers to their recovery? 

Clark: “If you have a kid who is 16 years old who is opioid dependent and needs a treatment center, where do you send them? It has to have a subset focus, because no parent is going to want to send them to a rehab center with 50 year old men and women. It is a struggle for us to find resources to treat them. If a facility does take teens, is that where the parents really want them to be? That's a struggle. If they’re younger that's even more difficult, so if they're 11 or 12 what would you do with them? Children’s health has a teen recovery program that serves teens ages 13-17, helping them address substance use or mental health issues that impact their lives. (Teen Recovery Program (childrens.com)). This program address education and support for the whole family.”

Clark: “As far as the biggest barriers to their recovery, in the pediatric world there are very few medication assisted treatment (MAT) options, i.e. methadone clinics, like there are for adults.   MAT requires a special certification to be able to treat patients that have substance use disorder. There are very few pediatric providers that have that specialty. Parents aren't always comfortable in treating teen addiction with medications like methadone or buprenorphine. From a pediatric standpoint, there are a lot of issues and barriers that come up when you start talking about getting treatment for addiction. Another issue for teens is you’re sending them back into the same atmosphere. If it’s a school issue where they’re getting their drugs, they still have to go to school so now what do we do?”

How do you think technology can help support recovery for Opioid users? (ie, identifying and easing capacity issues, reporting, monitoring?) 

Clark: “The communication and the collaboration between groups participating in the patient’s care is so important. Many people are involved including the physician treating the addiction, the pediatrician, the parents, the psychologist, the social worker, support groups, and the school. There are so many different people that have a piece of this pie and are invested in getting this kid help, but are they really talking to each other and making sure the resources are being utilized and consistently done? Mental health support goes right along in that. From a pediatric standpoint, we rely on getting the kids help from a variety of specialties. The addiction can be treated, but once they're out of the treatment center, they will need more support. The teen will need long term support from a mental health standpoint to maintain recovery. If everybody, including the patient, family and providers are communicating through the same platform, that would increase collaboration and ongoing communication and support leading to successful recovery.”

About Children’s Health

Children’s Health is committed to making life better for children. As one of the largest and most prestigious pediatric health care providers in the country and the leading pediatric health care system in North Texas, Children’s Health cares for children through more than 750,000 patient visits annually. The Children’s Health system includes its flagship hospital, Children’s Medical Center Dallas, as well as Children’s Medical Center Plano, Our Children’s House inpatient rehabilitation hospital, the Children’s Health Care Network, specialty centers, rehabilitation facilities, and physician services. Children’s Medical Center Dallas continues to be the only North Texas hospital to be ranked in 10 out of 10 pediatric specialties by U.S. News & World Report. Through its academic affiliation with UT Southwestern Medical Center, Children’s Health is a leader in life-changing treatments, innovative technology, and ground-breaking research. Children’s Health has the only Disease-Specific certification from the Joint commission for pediatric chronic pain.

About Lynn Clark

Lynn Clark is the Director of Advanced Practice for Anesthesiology for Children at Children’s Health. She has a background in pain management and specializes in pediatric care. “As the director for the group I help eliminate barriers, not only for the patients that we see, but also for my team and my staff to get the resources they need,” says Clark. One of Clark’s significant accomplishments was that her team implemented opioid prescribing guidelines for the hospital that helped to push the institution to recognize the importance of using opioids appropriately”.  Clark recalls a conversation she had with a provider where she thinks a “light bulb went off in her head” in regards to the number of opioid doses prescribed for acute pain and the prevention of excess drugs being left over. “Just being able to do that made my heart feel happy”, says Clark.