Trends in Prescription Opioid Use in Pediatric Emergency Department Patients Maryann Mazer-Amirshahi, PharmD, MD,*Þþ§ Peter M. Mullins, MA,Þ Irit R. Rasooly, AB,Þ John van den Anker, MD, PhD,Þþ§ and Jesse M. Pines, MD, MBA, MSCE*Þ Objective: In recent years, there has been increased emphasis on treating pain in emergency departments (EDs), coinciding with mount- ing concerns regarding the abuse potential of prescription opioids. In this study, we describe trends in opioid prescribing in pediatric patients in the US EDs over the past decade. Methods: Data from the 2001Y2010 National Hospital Ambulatory Medical Care Survey were analyzed and pain-related visits were iden- tified. Pain-related ED visits by pediatric patients (e19 y) where an opioid analgesic was administered or prescribed were tabulated by age category and year. Specific opioids analyzed included codeine, hydro- codone, hydromorphone, morphine, and oxycodone. The use patterns of nonopioid pain relievers were also investigated. Results were further strati- fied by Drug Enforcement Agency schedule and pain-related diagnosis. Results: The overall use of opioid analgesics in pain-related pedi- atric ED visits increased from 11.2% to 14.5% between 2001 and 2010 (P = 0.015). The use of Drug Enforcement Agency schedule II agents doubled from 3.6% in 2001 to 7.0% in 2010 (P G 0.001), whereas there was no significant increase in the use of schedule III, IV, and V agents (P = 0.34). Hydrocodone was the most frequently prescribed opioid analgesic. Increased opioid use was most dramatic in ED visits that involved adolescents. There was no significant increase in the use of nonopioid analgesics in pediatric ED patients (P = 0.086). Conclusions: Opioid use for pain-related pediatric ED visits has in- creased significantly from 2001 to 2010, particularly among adoles- cents. Emergency department providers must be vigilant in balancing pain relief with minimizing the adverse effects of opioid analgesics. Key Words: opioid analgesics, pediatric emergency department, prescribing trends (Pediatr Emer Care 2014;30: 00Y00) O ver the past decade, there has been an increased emphasis on identifying and treating pain in hospital-based emer- gency departments (EDs). 1Y3 Yet, despite the Joint Commission standard calling for pain to be assessed, treated, reassessed, and documented in every patient with a painful condition, 2 pain in pediatric ED patients has historically been poorly assessed and undertreated. 3Y5 Recent strides toward improving pain management in pediatric ED patients 3,6 have led to substantial increases in opioid analgesic prescriptions in this patient pop- ulation that parallel trends seen among adult patients. 1,3,7 In fact, the number of narcotic and controlled substance pre- scriptions written for adolescents and young adults nearly doubled between 1994 and 2007. 8 The increased use of opioid analgesics to treat pain has been concurrent with the rising rates of prescription opioid abuse and related morbidity and mortality. 9Y11 In particular, adolescent pa- tients are more likely to experiment with the nonmedical use of prescription opioids compared with their adult counterparts. 8,10,12 According to the 2010 National Survey on Drug Use and Health, prescription analgesics were the second most commonly abused substances by adolescents and young adults, surpassed only by marijuana. 13 In 1 study, 12.9% of high school seniors reported nonmedical use of a prescription opioid. 14 Up to 80% of the nonmedical users obtained opioids from a previous medical prescription, or a friend or a relative, 8,14,15 making these medi- cations easier for adolescents to obtain than other illicit drugs. Increased use and availability of prescription opioid analgesics have been associated with significant increases in overdoses, substance abuse, and long-term addiction in adolescents and young adults. 16,17 Opioid-related fatalities in adolescents more than doubled between 1980 and 2008. 11 Concerns have also been raised about the safety of opioids, particularly codeine, even in routine therapeutic use for chil- dren. Reports of adverse drug events, including death, by pa- tients with CYP2D6 polymorphisms that cause them to be ultrarapid metabolizers of codeine prompted the US Food and Drug Administration to issue medication safety warnings re- garding codeine. 18,19 Adverse events have been reported in postoperative tonsillectomy and adenoidectomy patients and in breastfeeding infants whose mothers are ultrarapid metabolizers of codeine, 20Y22 but there is limited data about the scope of codeine toxicity in the pediatric population. Opioid analgesics are often prescribed to pediatric patients in hospital-based EDs, yet the patterns of use over time, espe- cially in recent years, and the contributions of specific opioids have not been well characterized. This study examines national trends in opioid prescribing in pediatric ED visits between 2001 and 2010 by medication, age group, patient demographics, and institutional characteristics. METHODS Analyses were completed using publicly available data from the 2001Y2010 National Hospital Ambulatory Medical Care Survey (NHAMCS). Since 1992, NHAMCS data have been collected by the Centers for Disease Control and Preven- tion from approximately 30,000 to 40,000 abstracted charts in approximately 400 hospital-based EDs in noninstitutional, general, and short-stay hospitals. 23 Records are reviewed for missing visits or fields, and data processing is conducted at a central facility. Probability sampling weights are generated through a multistage estimation procedure to produce unbiased ORIGINAL ARTICLE Pediatric Emergency Care & Volume 30, Number 4, April 2014 www.pec-online.com 1 From the *Department of Emergency Medicine, The George Washington University; †The George Washington University School of Medicine and Health Sciences; ‡Department of Pediatrics, The George Washington Uni- versity; and §Department of Clinical Pharmacology, Children’s National Medical Center, Washington, DC. Disclosure: The authors declare no conflict of interest. Reprints: Maryann Mazer-Amirshahi, PharmD, MD, 111 Michigan AveNW, Washington, DC 20010 (e<mail: maryannmazer@gmail.com). The Abstract was accepted for presentation at the Pediatric Academic Society Annual Meeting in Washington last May 2013. Supplemental digital content is available for this article. 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