By Daniel L. Freidlin and Michael F. Bastone
Thursday, August 16, 2018
The opioid epidemic is not limited to adults. A 2016 National Survey on Drug Use and Health estimated that approximately 891,000 adolescents between the ages of 12 to 17 misused opioids in the prior year. Abuse of prescription drugs is often an easy gateway to illegal substance abuse because children can obtain opioids from friends or relatives, and often in their own home.
Opioid dependence in adolescents can lead to bad outcomes including poor academic performance, drug abuse and death. When these outcomes occur, patients or their parents frequently turn to litigation. An injured child typically draws sympathy from a jury and thus is an attractive prospective plaintiff to a personal injury attorney. Pediatricians are wise to use caution when prescribing opioids and incorporate dependence screenings in their general practice.
There are currently no national prescribing guidelines for opioids in the pediatric population. Few states have enacted legislation governing the prescription of opioids to children. In New York, Bill S5949 was recently passed in the Senate but has not yet passed into law. Bill S5949 proposes that physicians obtain written consent from a minor’s parent or guardian before prescribing opioids and discuss the risks of addiction. Some private organizations and health systems have issued opioid prescribing guidelines and recommendations. However, there remains no standardized formula that applies to prescribing opioids.
>With regard to dependence screening, pediatricians are on the front line for detection of abuse during annual well visits since most adolescents consider their physician an authoritative source for information about substance abuse and someone they can speak to in confidence. The federal Substance Abuse and Mental Health Services Administration and American Academy of Pediatrics (AAP) recommend that pediatricians use a three-part tool as part of their routine healthcare: SBIRT (screening, brief intervention, referral to treatment). Most pediatricians report screening patients for substance abuse, but the AAP cautions that only validated screening tools have proven efficacy. Brief intervention is an important step for all patients — even those who are not at risk for opioid abuse. Positive reinforcement and identifying risky behavior can benefit all patients, and discussing negative health consequences may be effective with patients who report some at risk behavior. Patients at immediate risk of harm or who are exhibiting substance abuse disorder should be referred for further treatment. Pediatricians must recognize the severity of opioid abuse as a disease and help their patients connect with the proper treatment.
In litigation, the standard of care is typically established through expert testimony. As a developing topic without national guidelines, the plaintiff’s expert can frame the standard of care in as restrictive a manner as possible to support the argument that the defendant pediatrician didn’t do enough to prevent or detect opioid dependence. Practitioners should consider modeling their practices around proposed laws and private organization guidelines including use of short-acting opioids rather than extended release formulations, using the lowest effective dose, asking about opioid use and disposal at follow-up visits, urine drug testing, consideration of family history, and use of an opioid minor consent form. Documenting these steps is also critical. A well-documented medical record, including screening tools utilized, patient counseling and education provided can assist the defense in proving that a bad outcome occurred despite utilization of appropriate preventative and screening methods.