Asking Saves Kids

Kiesha Fraser Doh, MD
kiesha.fraser @emory.edu

 

As of June 14th there have been 23 school shootings this year!  A total of 1,392 children have been killed or injured by firearms. In comparison during the influenza season from October 2017 to May 2018 a total of 172 children died. [1]This year of 2018 has been especially deadly for children, with 547 firearm deaths this year. [2]Thus more children died from firearm injuries this year compared to influenza deaths despite frequent media reports about influenza death compared to firearm injuries.

On June 21st, the first day of summer, the American Academy of Pediatrics and the Brady Campaign Against Gun Violence advocate for firearm safety in the home. This campaign encourages pediatricians to educate their patient’s parents to inquire about the presence of unlocked firearms in the homes their children visit. It is especially important in Georgia as 1 in 3 homes have firearms with the Georgia gun ownership rate of 31.6%.[3]

One third of all children live in homes with guns and 45% of gun-owning households do not store their firearms safely. [4] Seventy-five percent of children know where their parents store their guns. [5]  In 2016,  Georgia had the 4thhighest death rate in the nation by firearm injury which makes Georgians 2x as likely to die from a firearm injury in compared to New Yorkers[6].

Of note over the last few years at Children’s Healthcare of Atlanta on average we have seen 1 firearm injury every 2.5 weeks. In addition 10% of all Children’s trauma deaths in 2015 were firearm related.

When you consider where the US ranks in the world, 91% of firearm injuries in children of wealthy nations occur in the United States.[7]The U.S. General Accounting Office estimates that 31 percent of accidental deaths caused by firearms might be prevented with the addition of 2 devices: a childproof safety lock and a loading indicator.[8]

In our own Children’s ED-based study we were able to ascertain that when caregivers were educated to ask about firearm storage in the homes of their children’s playmates, 76% indicated they would. Interestingly, in this same study only 16% of parents reported ever being asked about presence of guns in their homes. In a recent published survey at some pediatric practices in Missouri 75% of parents felt pediatricians should ask about firearm safety but only 12% of parents reported having a conversation with their pediatrician.[9]

Thus it behooves us as pediatricians and medical care providers for children to ASK. Just as we ask about other important public safety initiative such as children riding in car seats, helmet while on bike and safe sleep. The AAP and the Brady Campaign have a website askingsaveskids.org which details ways pediatricians can educate their clients. In addition, he American College of Emergency Physicians has  developed a very handy discharge instruction sheet that can be distributed at each visit. (ACEP Discharge Instruction)

So what can you do as health care provider. #1 On June 21stASK parents about the presence of unlocked firearms?  #2 Educate your nursing staff (Asking Saves Kids Resources) #3 When screening for depressions also inquire if firearms are in the homes of your patients.

Don’t forget to ASK on Thursday, June 21st, because ASKING SAVES KIDS.

 

  1. Report WUIS. US Virologic Surveillance. Secondary US Virologic Surveillance 2018. www.cdc.gov.
  2. Gun Violence Archive. Secondary Gun Violence Archive 2018. gunviolencearchive.org.
  3. Kalesan B VM, Keyes K, Galea S. Gun Ownership and Social gun culture. Injury Prevention 2016:22:216-20
  4. Crifasi C DM, McGinty EE, Webster DW, Barry CL. Storage Practices of US Gun Owners in 2016. American Journal of Public Health 2018;108:532-37
  5. Baxley F, Matthew M. Parental Misperceptions about Children and Firearms. Archies of Pediatric Adolescent Medicine 2006;160:542-47
  6. Judd A. You’re twice as likely to be shot to death in Georgian than in New York (and other gun violence facts). Atlanta Journal Constitution2017.
  7. Grinshteyn E HD. Violent Death Rates: The US comparent with other High-income OECD Countries, 2010. American Journal of Medicine 2016;129:266-73
  8. Accidental Shootings: Many Deaths and Injuries Caused by Firearms Could Be Prevented. In: Office USGA, ed. Chairman Subcommittee on Antitrust, Monopolies, and I3usiness Rights, Committee on the PJudiciary,I7.S. Senate, 1991.
  9. Garbutt J BN, Dodd S, Sterkel R, Strunk R. What are Parents Willing to Discuss with Thei Pediatrian about Firearm Safety? A Parental Survey. Journal of Pediatrics 2016;179:166-71

 

Opioid Policies and Pediatrics: When the Pendulum Swings Children Will Get Hurt

Mike Greenwald, MD
mgreenw @emory.edu

 

 

 

 

 

 

Even if you have turned off all news sources over the past 2 years it would be hard to escape the urgent alarms regarding opioid misuse in the US. The statistics are remarkable.

  • Since 1999, overdose deaths involving opioids quadrupled.1
  • 2000-2015:greater than half a million people died from drug overdoses.
  • 91 Americans die every day from an opioid overdose.
  • 1999 to 2010: number of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled.2,3

This is compelling evidence that we have a problem – perhaps some more than others.  Opioid addiction is a frequent challenge for those caring for adults in the Emergency Department with some centers (e.g. rural) seeing more of this than others. Those who care for injured and ill children are left with 2 important questions: (1) What is the evidence regarding opioid addiction in children? (2) To what extent is the management of acute pain in children contributing to an increase in opioid related morbidity and mortality?

You would expect that a large percentage of opioids are prescribed from Emergency Department visits.  That is, after all, the place where we usually go to address severe pain.  Indeed, Emergency Medicine physicians have been targeted as one of the top specialties prescribing opioids. FDA data from 2009 shows that Emergency Physicians prescribe 4.7% of opioids.  However this reflects short acting opioids and the top prescribers are responsible for a far greater percentage: Family Medicine 26.7%, Internists 15.4%, Dentists 7.7%, Orthopedic surgeons 7.7%.4In a 2016 study by Chen et al. Emergency Physicians ranked 9thin opioid prescribing and the top 8 physician groups were responsible for more than 25 times as many opioid prescriptions as Emergency Physicians.5 An analysis of opioid prescribing and subsequent heroin indicates that “1 new heroin abuser might result from the administration of opioids to approximately 7,864 patients”.6  While prescribing practices by Emergency Physicians are a valid target for analysis and guidance, their contribution to the crisis is not clear.

Even less certain is the pediatric part of this equation. The relationship between opioid administration for pediatric pain and the development of opioid addiction is an uncommon and likely rare event.  In contrast, studies comparing opioid use for children and adults consistently demonstrate that children receive opioids in far lower weight based doses (approximately 50% in most studies) and frequency for similar conditions (e.g. post operative pain, procedural pain, acute pain).7

For the past several decades specialists and researchers in pediatric pain have gradually succeeded in dispelling the misconceptions that younger patients do not feel pain and that opioids are more dangerous for them than poorly treated pain.7One of the ironies of the current attention to prescribing practices is the change in terminology.  For many years advocates for better pain treatment have urged colleagues to stop using the term “narcotic” when describing opioid use for pain management.  The term has a pejorative connotation that many found counterproductive in treating pain. Now even lay people know the term “opioid” but in the context of opioid misuse.

Regardless of whether or not the administration of opioids to children in severe pain is contributing to an opioid crisis, the care of pediatric patients will no doubt be affected by the response for adult patients. A quick internet image search for “opioid billboard” reveals multiple versions of the one below:

This shocking message may be working. We now see phrases in the literature such as “Emergency Department: The birthplace of opioid addiction” and “Opioid-Free Emergency Departments”.  How will these attitudes and efforts eventually affect the care of your pediatric patients?

Pendulum swings in public opinion are not surprising.  Our challenge is to temper valid concerns with evidenced based approaches and thoughtful analysis to effectively address problems without creating new ones. Pediatricians need to be front and center in tackling these concerns and not cede that role to those with less expertise and perspective.

The first step is improved education and research. Who is at risk for addiction (e.g. age, co-morbidities)? Where are the misused opioids coming from (e.g. valid prescriptions vs illicit production or diversion)? Physicians who prescribe opioids should have a clear understanding of the pros and cons of opioids for different conditions and the difference between opioid tolerance, dependence, and addiction. Opioid tolerance and sometimes dependence is seen in the setting of regular use of opioids for many consecutive days. Opioid addiction in pediatrics remains a rare condition.

We can lower the risk of diversion by reducing the number of pills prescribed to adequately control severe acute pain without prohibiting the limited use of these medications in appropriate circumstances.  While individual experiences will vary, it is not unreasonable to anticipate a few days of moderate-severe pain after an acute injury or painful procedure.  In many cases regular use of ibuprofen (10mg/kg/dose q6hrs) supplemented with hydrocodone (0.15mg/kg/dose q4hrs prn) is a safe and effective way of getting through this period. Heed the phrase: The Right Tool for the Right Job.  Just as using opioids for less than severe pain introduces unnecessary risk, relying soley on low potency analgesics such as NSAIDs for severe pain will result in needless suffering and undermine the relationship with our patients and their families.

Finally, we can draw lessons from similar challenges in changing physician behavior such as the efforts to reduce inappropriate antibiotic use and ionizing radiation from unnecessary CT scans.  Like antibiotics and CT scans, opioids are an important tool for patient care that have a role for specific indications.  There is no doubt that creating guidelines for opioid use will present unique challenges as pain is ultimately a subjective data point and pain experiences are highly multi-factorial. That challenge, however, is not insurmountable and calls for a nuanced approach that addresses the concerns of patient, clinician, and society.

References

  1. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.
  2. US Department of Justice. Automation of Reports and Consolidated Orders System (ARCOS). Springfield, VA: US Department of Justice, Drug Enforcement Administration (DEA); 2011.
  3. Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999—2008.MMWR 2011; 60(43):1487-1492.
  4. Greene J. Amid Finger-Pointing for an Overdose Epidemic, Emergency Physicians Seek Pain Control Alternatives. Ann Emer Med 2016; (68;2) 17A-20A.
  5. Chen JH et al. Distribution of Opioids by different medicare prescribers. JAMA Int Med. 2016;176;259-261.
  6. Yealy DM and Green SM. Opioids and the Emergency Physician: Ducking Between Pendulum Swings. Annals Emerg Med 2016;68(2) 209-212.
  7. Finley GA and McGrath PJ (eds). Acute and Procedural Pain in Infants and Children. Seattle: IASP Press, 2001; 151, 159-160.